T H E STAT E O F T H E WO R L D ' S C H I L D R E N 2 019

Children, food
and nutrition
Growing well in a changing world
Published by UNICEF since 1980, The
State of the World’s Children report seeks to
deepen knowledge and raise awareness of
key issues affecting children and advocates for
solutions that improve children’s lives.
REPORT TEAM
Brian Keeley, Editor in Chief; Céline Little, Editor;
Juliano Diniz de Oliveira, Research and Policy
Specialist; Eric Zuehlke, Editor; Gregory Sclama,
Researcher; Kasper Vrolijk, Data Analyst;
Upasana Young, Programme Associate (Design);
Dawit Ghebremichael, Programme Associate;
and David Anthony, Chief of Policy Analysis.
NUTRITION DATA ANALYTICS AND
INNOVATION
Chika Hayashi, Richard Kumapley and Vrinda
Mehra.
EDITORIAL AND PRODUCTION
Samantha Wauchope, Production Specialist;
Ahmed Al Izzi Alnaqshbandi, Arabic Editor;
Carlos Perellon, Spanish Editor; Alix Reboul-
Salze, French Editor; Xinyi Ge and Yasmine
Hage, Research and Fact-checking; Adam
Woolf, Allison McKechnie and Deborah Yuill,
copy editors (Proseworks); and Germain Ake,
Distribution Associate.
GRAPHICS
Gabriela Montorzi, Nona Reuter, Shangning
Wang and Upasana Young.
MEDIA AND COMMUNICATIONS
Kurtis Albert Cooper, Sabrina Sidhu and Guy
Taylor.
RESEARCH
Background research for this report was
contributed by Cynthia M. Bulik, Clare Collins,
Fabrice DeClerck, Alessandro Demaio, Aman-
dine Garde, Jody Harris, Jenna Hollis, Peninah
Masibo, Karen McColl, Melissa Munn-Chernoff,
Nicholas Nisbett, Michael N. Onah, Kendra
Siekmans, Mimi Tatlow-Golden, Dylan Walters
and the Global Alliance for Improved Nutrition
(GAIN).
Perspective essays represent the personal
views of the authors and do not necessarily
reflect the position of the United Nations
Children’s Fund.
Unisex icons are often used throughout this report.
Permission is required to reproduce any part
of this publication.
Please contact:
Division of Communication, UNICEF, Attn:
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USA, Tel: +1 (212) 326-7434
Email: nyhqdoc.permit@unicef.org
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<data.unicef.org>.
Suggested citation: UNICEF (2019).
The State of the World’s Children 2019.
Children, Food and Nutrition: Growing well
in a changing world. UNICEF, New York.
ISBN: 978-92-806-5003-7
© United Nations Children’s Fund (UNICEF)
October 2019.
Cover photo: A girl eats lunch in the Hanaq
Chuquibamba community in Peru.
© UNICEF/Vilca/2019
ACKNOWLEDGEMENTS
This report is the result of collaboration among many
individuals and institutions. The report team thanks all
who gave so willingly of their time, expertise and energy,
in particular:
SENIOR ADVISORY GROUP
Victor M. Aguayo, Francesco Branca, Sandro Demaio,
Jessica Fanzo, Lawrence Haddad, Purnima Menon, Ellen
Piwoz, Victoria Quinn, Juan Rivera, Meera Shekar, Cesar
Victora, Keith West for strategic direction, technical
guidance, and policy advice.
INTERNAL ADVISORY GROUP
Maaike Arts, Yarlini Balarajan, France Begin, Silaja Birks,
Luisa Brumana, Lizette Burgers, Stefano Fedele, Alison
Fleet, Bernadette Gutmann, Diane Holland, Josephine Ippe,
Roland Kupka, Joan Matji, David Matern, Christiane Rudert,
Tamara Rusinow, Oren Schlein, Harriet Torlesse, Vilma Tyler,
Amirhossein Yarparvar and Noel Marie Zagre for reviewing
report drafts and providing guidance and advice.
DATA AND ANALYTICS
Vidhya Ganesh, Director, Division of Data, Analytics,
Planning & Monitoring; Robert Bain, Jan Beise, Claudia
Cappa, Liliana Carvajal, Allysha Choudhury, Enrique
Delamonica, Mamadou Salio Diallo, Karoline Hassfurter,
Chika Hayashi, Mark Hereward, Lucia Hug, Yves Jacques,
Aleya Khalifa, Julia Krasevec, Richard Kumapley, Sinae
Lee, Chibwe Lwamba, Vrinda Mehra, Suguru Mizunoya,
Padraic Murphy, Colleen Murray, Rada Noeva, Mohamed
Obaidy, Khin Wityee Oo, Lauren Pandolfelli, Hyunju Park,
Nicole Petrowski, Tyler Porth, Jennifer Raquejo, Nona
Reuter, David Sharrow, Tom Slaymaker, Sameen Wajid,
Danzhen You and Yanhong Zhang.
PROGRAMME DIVISION
Omar Abdi, Deputy Executive Director; Ted Chaiban,
Director; and Jens Aerts, Patty Alleman, Yousif Almasri,
Christina Calabrese, David Clark, Nita Dalmiya, Aashima
Garg, Thomas George, Saul Ignacio Guerrero Oteyza,
Jumana Haj-Ahmad, Tatiana Harmon, Andreas Hasman,
Sanda Hlaing, Annette Imohe, Jo Jewell, Emna Kayouli,
Ragini Khurana, Catherine Langevin-Falcon, Jennifer Lopez,
Isabel Madzorera, Erin McLean, Andrew Mok Yuan Min,
Reuel Kirathi Mungai, Louise Mwirigi, Gautam Narasimhan,
Cristina Hayde Perez Gonzalez, Nicole Ricasata, Dolores
Rio, Jessica Rodrigues, Joanna Rogowska, Mawuli Sablah,
Joseph Senesie, Sirjana Shakya, Deepika Sharma, Sagri
Singh, Ruth Situma, Irum Taqi, Rakshya Rajyashwori Thapa,
Vanya Tsutsui, Tamara Rusinow and Amy Wickham.
PRIVATE FUNDRAISING AND PARTNERSHIPS
Carlotta Barcaro, Jacquetta Hayes, Andrew Mawson,
Annabelle McDougall, Morel Naim and Keiko Sakamoto.
DIVISION OF COMMUNICATION
Charlotte Petri Gornitzka, Deputy Executive Director;
Paloma Escudero, Director; and Maurico Aguayo, Anna
Baldursdottir, Nigina Baykabulova, Penni Berns, Marissa
Buckanoff, Mariana Da Cunha Pinto Amaral, Jedd Flanscha,
Joe English, Angus Ingham, Deborah Toskovic Kavanagh,
Selenge Lkhagva, Gbolayemi Lufadeju, Najwa Mekki,
Christine Mills, Christine Nesbitt, Edita Nsubuga, Priyanka
Pruthi, Leah Selim, Michael Sidwell, Tanya Turkovich, Judith
Yemane and Dennis Yuen.
THE UNITED KINGDOM COMMITTEE FOR UNICEF
Pauline Castres, Kirtbir Chahal, Ceri Gautama, Roxanne
Portnoi and Liam Sollis.
UNICEF NEW YORK HEADQUARTERS
Diana Cordero, Kathleen Edison, Andres Franco, Hongwei
Gao, Dennis Gayanelo, Bindu Kotimreddy, Ganesh
Narahari, Brina Seidel and Arber Stublla.
SPECIAL THANKS TO
UNICEF colleagues in Afghanistan, Australia, Bangladesh,
China, Egypt, Ethiopia, Ghana, Guatemala, India,
Indonesia, Kyrgyzstan, Mexico, Nigeria, Philippines,
Serbia, the Sudan, the United States and Zimbabwe for
facilitating The State of the World’s Children workshops.
Alex Cadillo, Carolyn McCaffrey, Hugo Razuri, Carlos Rojas,
Maria Elena Ugaz, Ines Villar and Marilu Wiegold, in Lima,
Peru; Stephen Barrett, Marianne Clark-Hattingh, Maryam
Halim, Zouhair Rosli, Marc Vergara and Faradiza Zahri, in
Kuala Lumpur, Malaysia; Mx Balibago, Maria Evelyn Carpio,
Mariella Castillo, Zafrin Chowdhury, Rene Galera,Wigdan
Madani and Julia Rees, in Manila, Philippines; and Jee Hyun
Rah and Kate Rose in Jakarta, Indonesia, for their patience,
support and good humour during The State of the World’s
Children report team’s site visits.
UNICEF colleagues in Bangladesh, Belize, Brazil,
Burkina Faso, Cameroon, the Central African Republic,
Côte d’Ivoire, El Salvador, France, Ghana, Indonesia,
Liberia, Malawi, Malaysia, Mali, Mexico, Moldova,
Myanmar, Nigeria, Sierra Leone, South Africa, Eswatini,
Syria, Thailand, Tunisia, the United Kingdom, Ukraine,
Vietnam and Zimbabwe for participating in The State of
the World’s Children U-Report Poll, and UNICEF Global
Innovation Centre for carrying out and analysing the
SOWC U-Report Poll.
Alejandro Calvillo Unna, Hilal Elver, Inge Kauer, Peter Bakker,
Sania Nishtar, Scholastica Nguli, Sherrie Westin and Raya for
participating in the Perspectives essay series, and to Viktoria
Aberg, Hallie Ruvin, Moria Moderelli, Mark Wjine, Marisa
Macari, Alison Cairns, Kristin Heume and Melissa Shapiro
for their help with these essays.
Elyse Champaigne-Klassen, Catharine Fleming,
Girish Lala, Virginia Schmied and Amanda Third from
Western Sydney University for their work designing the
methodology and analysing the results from The State
of the World’s Children workshops held globally for this
report; and Peggy Koniz-Booher and Rafael Perez-
Escamilla, who served on the project’s Advisory Group.
Derek Headey for contributing to the development of
the box on food pricing and nutrition, based on The
relative caloric prices of healthy and unhealthy foods differ
systematically across income levels and continents by
Derek D. Headey and Harold H. Alderman.
The UNICEF Office of Research-Innocenti, the Global
Alliance for Improved Nutrition, the Nutrition Section
of UNICEF’s Programme Division and attendees at the
Food Systems for Children and Adolescents consultation,
Florence, 5–7 November, 2018.
Ian Au, Jose Cuesta, Tara Dooley, Elizabeth Fox, Nada
Hamadeh, Jens-Christian Holm, Sue Horton, Priscilla
Idele, Achila Imchen, Faizal Karmali, Manmeet Kuar,
Joseph Pell Lombardi, Makmende Media, Takaaki Masaki,
William Masters, David Nabarro, Dan Parker, Marko Olavi
Rissanen and The World Business Council for Sustainable
Development for their help and support.
Lisa Rogers from WHO for providing original data used in
this report.
UNICEF recognizes the support of the Kingdom of
the Netherlands and of Norway for this report.
The State of the World’s Children report is produced
by the Office of Global Insights and Policy
Laurence Chandy, Director.
 | 1

T H E STAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

CHILDREN, FOOD
AND NUTRITION
Growing well in a changing world
CONTENTS
Foreword 6
Key messages 8
How the triple burden of malnutrition harms children, adolescents and women 12

INTRODUCTION | Growing well in a changing world 14

A changing world 16
Malnutrition – a triple burden 16
Surviving, but not thriving 18
A greater focus on food systems 19
Making food systems work for children 20
About this report 22
Put children’s nutrition first 23
U-Report: What do adolescents and youth think about food and nutrition? 24
The State of the World's Children 2019 workshops with young people and mothers 26

01 Child malnutrition today 34

Child malnutrition today 36
Pulling the strands of malnutrition together 50
The role of food systems 54
What are the economic impacts of children’s malnutrition? 60
Special Section: Overweight and obesity in OECD and EU countries 48

02 Feeding a child for life 64

Early years: Vulnerability and opportunity (the first five years of life) 68
Middle childhood: A time of transition (ages 5–9) 81
Adolescence: Crucial years for lifelong nutrition (ages 10–19) 84
Special Section: What is a healthy diet? 90

03 Malnutrition in a changing world 94

Intergenerational cycles of malnutrition 101

Globalization 104
Urbanization 106
Climate shocks 112
Special Section: Girls and women need stronger support for better nutrition 102
Special Section: Nutrition in emergencies 116
04 Responses to malnutrition 120

How governments are responding to a growing momentum 123

Multiple responses to a multifaceted challenge: A systems approach 125
Putting children at the heart of food systems 132
Civil society and community responses 140
Some innovations in nutrition 148
Special Section: What does a systems approach to nutrition look like in practice? 128
Special Section: Influence of food marketing on children’s diets 144

05 An agenda to put children’s nutrition rights first 150

Empower families, children and young people to demand nutritious food 155
Drive food suppliers to do the right thing for children 156
Build healthy food environments for all children 157
Mobilize supportive systems to scale up nutrition results for all children 158
Collect, analyse and use good-quality data and evidence regularly to guide action and track progress 160
Special Section: Better data, better diets 162

Endnotes 166
Methodologies for The State of the World’s Children 2019 Workshops 178
Note on figures 179
Statistical tables 180

PERSPECTIVES

Upholding a child's right to food and nutrition, by Hilal Elver 32

Why is addressing children’s nutrition important for a country’s broader economic development? 62
  by Dr Sania Nishtar
Women lead the way in community-based child nutrition in rural Tanzania, by Scholastica Nguli 92
Sesame Workshop’s Raya teaches children healthy habits, by Sherrie Westin and Raya 118
The food industry must accelerate action to tackle the global nutrition crisis, by Inge Kauer 138
Grassroots activism in Mexico battles childhood obesity, by Alejandro Calvillo Unna 146
Working together to deliver healthy people and a healthy planet, by Peter Bakker 164
SPOTLIGHTS

United Kingdom: Poorest children at greater risk of overweight and food insecurity 53
A day is (almost) never enough: The daily life of a breastfeeding working mother in rural Laos 72
Complementary feeding and behaviour change in Rwanda 77
Mothers’ clubs take a stand against malnutrition in Haiti 79
In search of healthy habits in Indonesia 87
Child nutrition in poor urban areas of Kuala Lumpur 107
Childhood obesity: An urgent concern for China 109
Climate change threatens child nutrition in Bangladesh 113
A pioneering effort in food labelling 135
Surviving and thriving in Peru 141

TEXT BOXES


1.1 Caring for wasted children at home 41
1.2 How can agriculture better support nutrition? 55
2.1 Responsive feeding 80
2.2 Eating disorders, diet and adolescent mental health 88
3.1 Conceptual Framework of the Determinants of Maternal and Child Nutrition 97
3.2 Environmental enteric dysfunction 99
3.3 Additives 100
3.4 Epigenetics 101
3.5  Ultra-processed foods 104
3.6 Food prices and nutrition 110

GRAPHICS
How the triple burden of malnutrition harms children, adolescents and women 12
The Innocenti Framework on Food Systems for Children and Adolescents 56
Food and nutrition across childhood 66
How breastfeeding helps the mother and child 69
Conceptual Framework of the Determinants of Maternal and Child Nutrition 97
Nutrition and the Sustainable Development Goals 123
Multiple responses to a multifaceted challenge: A systems approach to nutrition 126
Food labelling systems 135
Put children’s nutrition first 152
FIGURES
A.1 Prevalence of children under 5 who are not growing well (stunted, wasted or overweight), 2018 17
1.1 Percentage of stunted children under 5, 2018 37
1.2 Projections for malnutrition in children under 5 compared to 2030 targets 40
1.3 Percentage of wasted children under 5, 2018 42
1.4 Percentage of children under 5 with hidden hunger 44
1.5 Percentage of overweight children under 5, 2018 46
1.6 Trend in percentage of countries by World Bank income group where at least 10 per cent of children 47
aged 5–19 years are overweight
1.7 Increase in overweight among under-5 and 5–19-year-old children and young people 47
1.8 Percentage of children and adolescents 5–19 years who are overweight in 41 OECD and EU countries 49
1.9 Number of countries with overlapping forms of childhood stunting, wasting, overweight and anaemia 50
1.10 Percentage of stunted children in poorest vs. richest households in low-, lower-middle-, upper-middle- 52
and high-income countries
2.1 Percentage of infants aged 0–5 months fed infant formula, by UNICEF region, 2018 70
2.2 Trends in percentage of infants aged 0–5 months exclusively breastfed, by UNICEF region, 71
around 2005 and around 2018
2.3 Percentage of children aged 6–23 months fed food groups, by type, global, 2018 74
2.4 Percentage of children aged 6–23 months eating at least 5 of 8 food groups 74
(Minimum Dietary Diversity), by UNICEF region, 2018
2.5 Percentage of children aged 6–23 months eating at least 5 of 8 food groups 74
by wealth quintile and place of residence, global, 2018
2.6 Percentage of children aged 6–23 months fed food groups, by type, 75
by World Bank income group, 2018
2.7 Percentage of children aged 6–23 months fed food groups, by type and age, global, 2018 75
2.8 Adolescent diets based on World Bank income group, 2008–2015 85
3.1 Prevalence of stunting, thinness and overweight among children (7–18 years old) in China, 1985–2014 109

STATISICAL TABLES

General note on the data 180
Child mortality estimates 181
Regional classifications 182
Notes on specific tables 183
Number of under-five deaths and under-five 190
  mortality by country in 2018
Demographics 192
Child mortality 196
Maternal and newborn health 200
Child health 204
HIV/AIDS: Epidemiology 208
HIV/AIDS: Intervention coverage 212
Nutrition: Newborns, infants and 216
  young children
Nutrition: Preschool/School age children, 220
  women and households
Early childhood development 224
Education 228
Child protection 232
Social protection and equity 236
WASH 240
Adolescents 244
Economic indicators 248
Women’s economic empowerment 252
 6 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
Foreword
In the spoonful a mother or father feeds
to a toddler, food is love. In the feast a
family cooks for a child’s coming of age,
food is community. In the shouts and
laughter of teenagers sharing snacks
after school, food is joy. And for every
© UNICEF/UN0154449/Nesbitt
child and young person everywhere,
food is life – a fundamental right and a
foundation of healthy nutrition and sound
physical and mental development.
Sadly, as this State of the World’s
Children report shows, far too many
of our children and young people are
not getting the diets they need, which
is undermining their capacity to grow,
develop and learn to their full potential.
That hurts not just individual children
and young people, it hurts us all.
This situation forces us to ask some
difficult questions: How is it in the 21st
century that we still have 149 million
children under 5 with stunting and
almost 50 million with wasting? How is it
possible that overweight and obesity in
children and young people are continuing
to rise, and increasingly among the poor?
And why are healthy diets becoming
more expensive while unhealthy, non-
nutritious diets are becoming cheaper?
Nutrition has long been at the core of
UNICEF’s work. In 2018, we helped
provide life-saving therapeutic feeding
for 4.1 million children with severe
acute malnutrition; we improved
the quality of diets for over 15.6
million children through home-based
fortification; we supported programmes
to prevent anaemia and other forms of
malnutrition for 58 million adolescent
girls and boys; and we ensured that
over 300 million children received
services for the prevention of stunting
and other forms of malnutrition.
Nutrition has also long been key to
our thought leadership. In 1990, our
pioneering malnutrition framework broke
new ground in setting out the multiple
causes of poor nutrition. In 2019,
we have rethought our framework to
emphasize what creates good nutrition
– from the diets of children and women
to the care they benefit from, the food
environments in which they live, and the
ways in which our societies underpin
the right to adequate nutrition through
our values and political commitment.
Each of these determinants presents an
opportunity to improve the nutrition of
our children, young people and women.

As Executive Director of UNICEF and Chair
of the Lead Group of the Scaling Up Nutrition
Movement, I want to emphasize again
my commitment, and the commitment of
UNICEF, to use all of these opportunities
to work for better nutrition for every child,
especially in the crucial first 1,000 days –
from conception to age two years – and
during adolescence, the two unparalleled
windows of opportunity. We are underscoring
this commitment by launching this report
along with UNICEF’s new nutrition strategy,
which sets out our priorities and plans to
improve the nutrition of children, young
people and women, in the years to come.
We already know so much of what works
to prevent malnutrition in all its forms, from
conception, through early childhood and
into adolescence. But this is a battle we
cannot win on our own. It needs the political
determination of national governments,
backed by clear financial commitments,
as well as policies and incentives that
encourage the private sector’s investment
in nutritious, safe and affordable food for
children, young people, women and families.
And, increasingly, it needs a determination
to make children’s nutrition a priority across
not just the food system but also in the
health, water and sanitation, education
F O R E WO R D | 7
and social protection systems. Success in
each of these supports success in all.
Young people and women know the value
of good nutrition and eating well. “Eating
healthily is being responsible for your own
health,” said a 16-year-old girl in China during
one of more than 70 workshops organized
for this report. In India, a 13-year-old girl
told us that “food is important for us so that
we are able to study well.” They are clear,
too, on the barriers to healthy nutrition: “I
don’t have enough money to buy food for
me and my baby,” a 20-year-old mother
said in Guatemala; “I lack knowledge
about what kinds of food are healthy,”
an 18-year-old girl said in Zimbabwe.
Good nutrition paves the way for a fair
chance in life. Let us work together to
lower these barriers and to ensure that
every child, young person and woman
has the nutritious, safe, affordable and
sustainable diets they need at every
moment of life to meet their full potential.
Henrietta H. Fore
UNICEF Executive Director
8 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
A child sells snacks to other children outside a clinic in Gaza City, State of Palestine. © UNICEF/UN068011/El Baba
Children, food and nutrition | Growing well in a changing world
Key Messages
At least 1 in 3 children under 5 is undernourished or
overweight and 1 in 2 suffers from hidden hunger,
undermining the capacity of millions of children to
grow and develop to their full potential.
†† Globally, at least 1 in 3 children under 5 is not
growing well due to malnutrition in its more
visible forms: stunting, wasting and overweight.
†† Globally, at least 1 in 2 children under 5 suffers
from hidden hunger due to deficiencies in
vitamins and other essential nutrients.
†† Undernutrition continues to exert a heavy toll.
In 2018, almost 200 million children under 5
suffered from stunting or wasting while at least
340 million suffered from hidden hunger.
†† Overweight and obesity continue to rise. From
2000–2016, the proportion of overweight children
(5 to 19 years old) rose from 1 in 10 to almost 1 in 5.
†† The number of stunted children has declined
in all continents, except in Africa while the
number of overweight children has increased
in all continents, including in Africa.
The triple burden of malnutrition – undernutrition,
hidden hunger and overweight – threatens the
survival, growth and development of children, young
people, economies and nations.
†† Stunting – a clear sign that children in a country
are not developing well – is both a symptom of
past deprivation and a predictor of future poverty.
†† Wasting can be lethal for children, particularly
in its most severe forms. Contrary to common
belief, most wasted children around the world
live in Asia and not in emergency settings.
†† Hidden hunger harms children and women. Iron
deficiency reduces children’s ability to learn and
iron deficiency anaemia increases women’s
risk of death during or shortly after childbirth.
†† Child overweight can lead to early onset of
type-2 diabetes, stigmatization and depression,
and is a strong predictor of adult obesity, with
serious health and economic consequences.
†† The greatest burden of all forms of malnutrition
is shouldered by children and young people from
the poorest and most marginalized communities,
perpetuating poverty across generations.

The triple burden of malnutrition is driven by the
poor quality of children’s diets: 2 in 3 children are
not fed the minimum recommended diverse diet
for healthy growth and development.
†† Only 2 in 5 infants under six months of age
are exclusively breastfed, as recommended.
Breastfeeding could save the lives of
820,000 children annually worldwide.
†† Use of breastmilk substitutes is of concern.
Sales of milk-based formula grew by 41 per
cent globally and by 72 per cent in upper
middle-income countries such as Brazil,
China and Turkey from 2008–2013.
†† Poor diets drive malnutrition in early childhood:
44 per cent of children aged 6 to 23 months
are not fed fruits or vegetables and 59 per
cent are not fed eggs, dairy, fish or meat.
†† Only 1 in 5 children aged 6 to 23 months from
the poorest households and rural areas is
fed the minimum recommended diverse diet
for healthy growth and brain development.
†† Many school-going adolescents consume
highly processed foods: 42 per cent drink
carbonated soft drinks at least once a day and
46 per cent eat fast food at least once a week.
Globalization, urbanization, inequities,
humanitarian crises and climate shocks are
driving unprecedented negative changes in the
nutrition situation of children around the world.
†† Globalization is shaping food options and
choices: 77 per cent of processed food sales
worldwide are controlled by just 100 large firms.
†† In cities, many poor children live in ‘food deserts’,
facing an absence of healthy food options, or in
‘food swamps’, confronted with an abundance
of high-calorie, low-nutrient, processed foods.
K E Y M E S SAG E S | 9
†† Poor families tend to select low-quality food
that costs less. Because of poverty and
exclusion, the most disadvantaged children
face the greatest risk of all forms of malnutrition.
†† Climate shocks, loss of biodiversity, and
damage to water, air and soil are worsening
the nutritional prospects of millions of children
and young people, especially among the poor.
†† UNICEF and its partners treated more than
3.4 million children with severe malnutrition in
humanitarian settings in 2018, from Afghanistan
and Yemen to Nigeria and South Sudan.
Improving children’s nutrition requires food systems
to deliver nutritious, safe, affordable and sustainable
diets for all children.
†† Millions of children are eating too little of what
they need, and millions are eating too much of
what they don’t need: poor diets are now the
main risk factor for the global burden of disease.
†† National food systems must put children’s
nutrition at the heart of their work because
their nutritional needs are unique and meeting
them is critical for sustainable development.
†† Financial incentives should be used to reward
actors who increase the availability of healthy
and affordable foods in markets and other points
of sale especially in low-income communities.
†† Financial disincentives on unhealthy foods can
improve children’s diets. For example, taxes on
sugary foods and beverages can reduce their
consumption by children and adolescents.
†† Fortification of complementary foods and
staple foods with micronutrients can be a
cost-effective intervention to combat hidden
hunger in children, young people and
women.
10 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
Food environments are crucial. When healthy
options are affordable, convenient and desirable,
children and families make better food choices.
†† Children, adolescents, young people, parents
and families need support to demand
nutritious foods, but food environments
need to promote and support healthy diets.
†† Innovative, fun, memorable and engaging
communication strategies to promote healthy
eating can leverage the cultural and social
aspirations of children, adolescents and families.
†† Legislation plays a key role in promoting good
diets for children, such as by regulating the
marketing of breastmilk substitutes to mothers
and families, and of unhealthy food to children.
†† The marketing of unhealthy foods and sugar-
sweetened beverages is directly linked to
growing overweight and obesity in children.
†† Front of package labelling – visible, accurate
and easy to understand – helps children, young
people and families make healthier food choices
and incentivizes suppliers to deliver healthy food.
†† Governments need to promote healthy food
environments in schools, including healthy meals
and limiting the sale and advertising of ‘junk
food’ in proximity to schools and playgrounds.
†† The health, water and sanitation, education
and social protection systems also have crucial
roles to play in promoting and supporting good
nutrition for children, adolescents and women.
Investing in nutrition for children and young people
is a cornerstone investment if the world is to achieve
the Sustainable Development Goals by 2030.
†† Investing in child nutrition is key to human
capital formation because nutrition is central
to children’s growth, cognitive development,
school performance and future productivity.
†† A large and young labour force – with
a great creativity and productivity
potential – is emerging in Africa and
Asia. However, malnutrition risks
limiting this demographic dividend.
†† Returns from investment in nutrition
are high. For example, every dollar
invested in reducing stunting generates
an economic return equivalent to about
US$18 in high-burden countries.
One word must be at the heart of our response
to children’s malnutrition – action. We need action
that reflects the core role of food systems, that
strengthens the supply of – and demand for – better
food, that improves children’s food environments,
and leverages the role of key supportive systems.
With action comes another imperative: accountability.
Progress must be measured, shared, acted on and
celebrated. Sound nutrition is fundamental to children’s
well-being and the achievement of the Sustainable
Development Goals. It needs to be put at the heart of
government policy and supported by key stakeholders,
including civil society and the private sector.
The State of the World’s Children 2019 report
concludes with the following Agenda to Put
Children’s Nutrition Rights First:
1 Empower families, children and young
people to demand nutritious food.
2 Drive food suppliers to do the right thing for
children.
3 Build healthy food environments for all children.
4 Mobilize supportive systems – health, water
and sanitation, education and social protection
– to scale up nutrition results for all children.
5 Collect, analyse and use good-quality
data and evidence regularly to guide
action and track progress.n
Girl , 8, enjoys a fizzy drink just purchased from a local street vendor
in Pretoria, South Africa. © UNICEF/UN0343581/Hearfield
K E Y M E S SAG E S | 11
12 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

How the triple burden of malnutrition

harms children, adolescents and women

Undernutrition: stunting and wasting

• Poor growth, infection and death
• Poor cognition, school-readiness and school performance
• Poor earning potential later in life

Hidden hunger: deficiencies in

micronutrients
• Poor growth and development
• Poor immunity and tissue development
• Poor health and risk of death

Overweight
(including obesity)
• Short-term: cardiovascular
problems, infections and
poor self-esteem
• Long-term: obesity,
diabetes, and other
metabolic disorders

CHILDREN AND ADOLESCENTS

 D I D YO U K N OW | 13

Undernutrition:
stunting and
149 million
underweight children
under-5
• Perinatal stunted
complications
• Prematurity and
low birth weight
• Chronic diseases Almost 50
for child in later life million
children
under-5
wasted

Hidden hunger:
40 million
deficiencies in children
micronutrients under-5
overweight
• Maternal
mortality and
morbidity
• Neural tube
defects in More than 1
newborns in 3 children
• Prematurity, low not growing
birth weight and well
impaired cognitive
development
in newborns

Over 340 million

children suffering
Overweight from deficiencies
of essential
(including obesity) micronutrients
(vitamins and
• Gestational minerals)
diabetes and
pre-eclampsia
• Obstetric At least 1 in 2
complications children with
• Overweight and hidden hunger
chronic disease
for child in later life

PREGNANT WOMEN
 GROWING WELL
Introduction

IN A CHANGING
WORLD
 I N T RO D U C T I O N | G ROW I N G W E L L I N A C H A N G I N G WO R L D » 15

At least one in three children is not getting the †† Globally, at least 1 in 3

children is not growing
nutrition they need to grow well, particularly in well due to malnutrition
in its more visible forms:
stunting, wasting and
the crucial first 1,000 days – from conception to overweight. At least 1
in 2 suffers from hidden
the child's second birthday – and often beyond. hunger due to deficiencies
– often not visible – in
An increasing number of children and young essential nutrients.

†† This triple burden

people are surviving, but far too few are thriving of malnutrition –
undernutrition, hidden
because of malnutrition. To meet the challenges hunger and overweight
undermines children's
of the 21st century, we need to recognize the health and physical and
cognitive development.

impact of forces like urbanization and globalization †† Food systems are key:
They need to provide
on nutrition, and focus increasingly on using local children and young
people with diets that
and global food systems to improve the diets of are nutritious, safe,
affordable and
children, young people and women. sustainable.

A mother prepares food in Korhogo, in the North of Côte d'Ivoire. © UNICEF/UN0241733/Dejongh

 16 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
–
mal·nu·tri·tion
/, maln(y)oo'triSH( )n/ e A changing world
noun It is 20 years since The State of the World’s
Children report last examined children’s
lack of proper nutrition. In that time, much has changed.
nutrition, caused by
not having enough We have changed where we live: more
to eat, not eating and more families have left the farm
enough of the right and the countryside behind and have
things, or being un- moved to cities, a global shift that will
able to use the food only grow in the years to come.
that one does eat
We have changed our roles. In societies
around the world, women are increasingly
joining the formal workforce, balancing work
responsibilities with their role as primary
caregivers, and often with little support from
families, employers or society at large.
The conditions of life on our planet have
changed. The crisis of climate change,
the loss of biodiversity, and the damage
done to water, air and soil, now raise
concerns over whether we can feed
this generation of children sustainably,
never mind the generations to come.
Finally, we have changed what we eat.
We are leaving behind traditional and
indigenous diets and embracing modern
diets that are frequently high in sugars
and fats, low in essential nutrients and
fibre, and often highly processed.
This is the backdrop to children’s
malnutrition today. As with so much
else, it, too, is changing. A word once
inextricably linked in the public’s mind
with images of hunger and famine,
malnutrition must now be used to describe
a much broader swathe of children –
children with stunting and wasting, but
Bad diets across also those suffering from the hidden
the population are hunger of deficiencies in essential
now the leading vitamins and minerals, as well as the
cause of death growing numbers of children and young
worldwide people who are overweight or obese.
These are the children who
are not growing well.
Their numbers are worryingly high
(see Figure A.1). Globally, at least
one in three children under the age
of 5 is stunted, wasted or overweight
and, in some cases, suffers from a
combination of two of these forms of
malnutrition. Further, at least one in two
children suffers from hidden hunger
due to deficiencies – often not visible
– in vitamins and essential nutrients,
which can harm survival, growth and
development at every stage of life.
Malnutrition – a triple
burden
The children who are not growing well
are the victims of the three strands of
the triple burden of malnutrition that
is rapidly emerging in communities
around the world, including in some
of the world’s poorest countries.
The first strand is undernutrition. Despite
some declines, undernutrition continues
to affect tens of millions of children. Its
presence is visible in the stunted bodies
of children deprived of adequate nutrition
in the crucial first 1,000 days – from
conception to the child’s second birthday
– and often beyond. These children may
carry the burden of early stunting for the
rest of their lives and may never meet
their full physical and intellectual potential.
Undernutrition is also evident in the
wasted bodies of children at any stage
of life when circumstances such as food
shortages, poor feeding practices and
infection, often compounded by poverty,
humanitarian crises and conflict, deprive
them of adequate nutrition and, in far too
 I N T RO D U C T I O N | G ROW I N G W E L L I N A C H A N G I N G WO R L D » 17

Where are children not growing well?

FIGURE A.1 | Prevalence of children under 5 who are not growing well (stunted, wasted or overweight), 2018

Eastern Europe
and Central Asia
22.5%

North America
11.6%
East Asia
and the Pacific
17.2%
Middle
East and
North Africa
West and 32.4%
Central Africa
39.4% South Asia
49.9%

Eastern and
Latin America
Southern Africa
and the Caribbean
42.1%
16.5%

%
No data No recent data Less than 10.0 10.0–19.9 20.0–29.9 30.0–39.9 40.0–49.9 50.0–59.9 Greater than 60

1 in 3 children
worldwide under
the age of 5 is not
growing well

Note: Country data are the most recent available estimate between 2006 and 2018; where only data prior to 2000 are available, the dark grey color denoting no recent data is used. The
designations employed in this publication and the presentation of the material do not imply on the part of the United Nations Children’s Fund (UNICEF) the expression of any opinion whatsoever
concerning the legal status of any country or territory, or of its authorities or the delimitations of its frontiers.
’Growing well‘ is defined as free from stunting, wasting and overweight. See Note on Figures on p. 179 for more information.
Source: UNICEF analysis of UNICEF/World Health Organization/World Bank Group Joint Malnutrition Estimates, 2019 edition. Levels and trends in child malnutrition: Key findings of the 2019
edition of the Joint Child Malnutrition Estimates.
18 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
More children and
young people are
surviving, but far
too few are thriving
many cases, result in death. In 2018, 149
million children under 5 were stunted
and almost 50 million were wasted.
The second strand of malnutrition is
hidden hunger. Deficiencies of essential
vitamins and minerals – often referred
to as micronutrients – rob children
of their vitality at every stage of life
and undermine the health and well-
being of children, young people and
women. This heavy toll is made all the
more insidious by the fact that hidden
hunger is rarely noticed until it is too
late to do anything. The numbers of
children affected by hidden hunger
are striking. Based on the most recent
data available, UNICEF estimates that
at least 340 million children under 5
suffer from micronutrient deficiencies.1
The third strand is overweight and, in its
more severe form, obesity. The numbers
of obese girls and boys between the
ages of 5 and 19 have soared since the
mid-1970s, rising by between 10- and 12-
fold globally.2 Overweight, long thought
of as a condition of the wealthy, is now
increasingly a condition of the poor,
reflecting the greater availability of ‘cheap
calories’ from fatty and sugary foods
in almost every country in the world. It
brings with it a heightened risk of non-
communicable diseases, such as type
2 diabetes and coronary heart disease.
Analysis carried out as part of the Global
Burden of Disease study suggests that
diets lacking adequate nutrition are now
the leading cause of death worldwide.3
Behind all these numbers are the real
lives of the children and women. They
are the toddlers like Moteab, who, like
hundreds of thousands of other children
in Yemen, has had to fight for his life
from severe wasting. Moteab survived,
but many other children living through
conflicts and humanitarian crises around
the world have not. They are the infants
like Joemar in the Philippines, who
live far from warzones but who also
suffer from severe wasting. They are
the children of mothers like Uruma in
Tanzania, who go to school on an empty
stomach because their parents cannot
afford to buy food. They are the teens
like Zahfa in Indonesia, who get too little
time to exercise and who are surrounded
by unhealthy food options. And they
are the mothers like Xaiathon in rural
Laos, who must balance breastfeeding
her child and feeding her family with
the demands of working on a farm.
Surviving, but not thriving
The state of children’s malnutrition
in the 21st century can be summed
up like this: more children and young
people are surviving, but far too few
are thriving. They are not thriving in
the crucial first 1,000 days, when the
foundations for healthy, lifelong physical
growth and mental development are
laid. And they are not thriving at other
crucial development stages of life across
childhood and into adolescence.
Malnutrition has many causes. A
mother’s nutritional status, for example,
profoundly affects her child’s survival,
growth and development, as does
the child’s feeding in the first hours
and days of life. For far too many
children, the causes of malnutrition
also include poor access to essential
health services and to clean water and
adequate sanitation, which can lead to
illnesses that prevent the child from
absorbing nutrients (see Chapter 3).

But to understand malnutrition, there
is an increasing need to focus on food
and diet, and at every stage of the
child’s and young person’s life. The
picture that emerges is a troubling one:
far too many children and young
people are eating too little healthy
food and too much unhealthy food.
These problems start early on. In their first
six months, only two out of five children
are being exclusively breastfed, depriving
them of the best food a baby can get.
When it comes to the ‘first foods’ (or
complementary foods) that infants should
start consuming at around the age of 6
months, these too are, in far too many
cases, not meeting children’s needs.
Fewer than one in three children between
6 and 23 months is eating the diverse
diet that can support their rapidly growing
bodies and brains. For the poorest children,
the proportion falls to only one in five.
Among older children, low consumption of
fruits and vegetables is widespread.4 This
is true, too, of many adolescents, many of
whom also regularly miss or skip breakfast
and consume soft drinks and fast food.5
The diets of children today increasingly
reflect the global ‘nutrition transition’,
which is seeing communities leave
behind often more healthy, traditional
diets in favour of modern diets.6 For many
families, especially poorer families, this
means an increasing reliance on highly
processed foods, which can be high in
saturated fat, sugar and sodium and low
in essential nutrients and fibre, as well
as on ‘ultra-processed’ foods, which
have been characterized as formulations
containing little or no whole food and
which are extremely palatable, highly
energy dense, and low in essential
nutrients.7 Often missing from these diets
are whole grains, fruit, nuts and seeds,
vegetables, and omega-3 fatty acids.8
I N T RO D U C T I O N | G ROW I N G W E L L I N A C H A N G I N G WO R L D » 19
There is increasing concern about the
impact of these diets on human health.
Much of the focus is on rising overweight
and obesity, but modern diets are also
implicated in undernutrition. In Nepal,
a recent study suggested that children
under 2 may be getting on average
a quarter of their energy intake from
items such as biscuits, instant noodles
and juice drinks, which is lowering
their intake of essential vitamins and
minerals. Children eating the most of
these sorts of snacks and beverages
were shorter than their peers. 9
A greater focus
on food systems
Health impacts are not the only concern
around modern diets. In a world facing
multiple environmental crises, there is
also concern about the sustainability of
these diets. Food production accounts
for almost a third of greenhouse gas
emissions and 70 per cent of fresh water
use, and current modes of food production
are the leading cause of environmental
change.10 Climate-related shocks, such
as flooding, are already challenging the
capacity of some communities to feed
themselves and are exposing children to
increased risk from waterborne diseases.
If current trends continue, the impact
of food production on the environment
will only grow, with food demand set to
increase by at least half by mid-century.11
This demand will have to be satisfied
against the backdrop of a world that, after
decades of decline, is seeing a slow rise in Far too many
hunger, with 820 million people suffering children and young
from undernourishment in 2018.12 people are eating
too little healthy
In response to these challenges, and in food and too much
this UN Decade of Action on Nutrition, unhealthy food
20 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

To make food
systems work better
for children, we
need to understand
the unique
nutritional needs
of children at every
stage of life
there is a growing focus on the role of
food systems – all the elements and
activities involved in the “production,
processing, distribution, preparation and
consumption of food” as well as the
outcomes of these activities, including
nutrition and health.13 In other words,
everything and everyone involved in
bringing food ‘from farm to mouth’.
Food systems are becoming more
complex. More food now crosses
borders, and production is con-
centrated in the hands of a relatively
small number of businesses – just 100
large firms account for 77 per cent
of processed food sales worldwide.14
For families around the world,
business is playing a growing role
in providing the food they eat and,
through marketing, in shaping what
they want to eat and their aspirations.
Understanding how food systems work
is essential to improving our diets.
Far too often, the interests of a very
important group of people are left out
of food systems analysis – children.
This is a dangerous omission. Children
are a unique group. Poor diets have
lifelong impacts on their physical
growth and brain development. That
is why they must be at the heart of
our thinking about food systems. If
food systems deliver for children,
they are delivering for us all.
Making food systems
work for children
combat malnutrition and disease.
That goal has not changed. What has
changed are the contexts in which this
needs to happen, and the realization
that food systems are a key – and
underappreciated – part of the puzzle.
To make food systems work better for
children, we need to understand the
unique nutritional needs of children
at every stage of life, particularly in the
first 1,000 days – but also on day 1,001,
and then on through the school years,
when a well-nourished child can focus
better and learn more in the classroom,
and throughout the vital years of
adolescence, when physical and mental
development again speeds up and when
lifelong eating habits are established.
To make food systems work better
for children, we need to understand
the rapidly evolving contexts that
are shaping and reshaping children’s
diets. Climate change, urbanization
and globalization are profoundly
altering how and what children eat,
as well as the social and cultural
values we attach to food.
To make food systems work better
for children, we need to respond
to the challenges children, young
people, women and families are facing
around the world – food deserts,
the high cost of healthy foods, time
pressures, the limited availability of
nutrient-rich foods, including fruits and
vegetables – and the pressure many
children, adolescents and families feel
from marketing and advertising.

To make food systems work better

Thirty years ago, the Convention for children, we need to address the
on the Rights of the Child spoke of scandal of child labour in agriculture
the need to provide children with and food production, much of which
“adequate nutritious foods” to is hazardous. In 2016, 108 million

children aged between 5 and 17 were
engaged in agricultural labour, accounting
for 71 per cent of all child labour.15
And to make food systems work better for
children, we need to ensure food systems
work with, and are not undermined by, all
the other systems that affect children’s
lives. The health, water and sanitation,
education and social protection systems
must all work together to provide children
and their families with the knowledge,
support and services they need to
ensure that nutritious diets translate
into better growth and development.
I N T RO D U C T I O N | G ROW I N G W E L L I N A C H A N G I N G WO R L D » 21
When food systems work better for A father carries his daughter of 7
months through a grocery store in
children, we all benefit. Good nutrition Maitland, Cape Town, South Africa.
can break the vicious intergenerational © UNICEF/UN0315717/Sokol
cycles through which malnutrition
perpetuates poverty, and poverty
perpetuates malnutrition. Children
who are well nourished have a Good nutrition can
firm foundation from which they break the vicious
can develop to their full potential. intergenerational
When children do that, societies and cycles through
economies develop better, too.16, 17 which malnutrition
perpetuates
Our goal must be to give children poverty, and
diets that are nutritious, safe, poverty perpetuates
affordable and sustainable.¢ malnutrition
22 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

About this report

This edition of The State of the World’s Children report examines children, food and
nutrition. It seeks to deepen understanding around the causes and consequences of
children’s malnutrition in all its forms and to highlight how governments, business,
families and other stakeholders can best respond.

Chapter 1 examines the changing face of children’s malnutrition. It sets out the current state
of undernutrition, hidden hunger and overweight worldwide, explores the lives of children
affected by severe acute malnutrition, and investigates the cost to children and to us all of
malnutrition. It also introduces in greater detail some of the main ideas around food systems.

Chapter 2 investigates malnutrition across the life of the child, from development in the
womb to the point where a young person is entering adulthood. It explores the developmental
impacts of malnutrition and the unique nutritional needs and influences at each stage
of childhood.

Chapter 3 explores malnutrition in a changing world. Globalization and urbanization are

changing children’s diets while disasters and conflict worsen nutritional prospects for millions
of poor and excluded children. Without transformation of today’s food systems, healthy diets
will remain out of reach for the most vulnerable children, perpetuating intergenerational
cycles of disadvantage.

Chapter 4 examines the current state of responses to children’s malnutrition, including the
increased attention – at the global and national level – to the importance of addressing mal-
nutrition across multiple systems, with particular emphasis on the food system in synergy
with the health, water and sanitation, education and social protection systems, and on how
different stakeholders are responding.

Finally, Chapter 5 sets out an agenda to put children’s nutrition rights first (see opposite
page). This agenda is driven by two imperatives. First, children have unique nutritional needs
and can suffer unique harm from malnutrition. Putting children’s needs first is key to ensuring
that every child and young person has the nutrition they need to get the best start in life.
Second, all children and young people will need nutritious, safe, affordable and sustainable
diets if societies are to meet the economic, social and environmental challenges of our
changing world in the 21st century.
 I N T RO D U C T I O N | G ROW I N G W E L L I N A C H A N G I N G WO R L D » 23

Put children’s nutrition first 1 in 3 children

is not growing well

1. Empower families, children and young people to demand nutritious food

Demand affects supply as food producers respond to consumers’ behaviours and aspirations.
When healthy options are affordable, convenient and desirable, parents and caregivers
make better food choices for children. As children grow older, knowledge and information
can make them powerful agents of change. Stimulating demand for nutritious foods means
not only educating consumers on the benefits of healthy diets, but also leveraging cultural
and social aspirations.
1 in 3 children
1 Empower families, children and young
people to demand nutritious food
For every child
is not growing well to grow well

SOCIAL WATER &

2. Drive food suppliers to do the right thing for children 1 in 3 children PROTECTION
For every child
SANITATION
18%
is not growing well to grow well

Demand alone is not enough: healthy food must be available, affordable, safe and convenient.
FOOD

Food producers and suppliers have a key role to play, and so do governments, which must
create a level playing field for all producers and suppliers and help ensure that their actions HEALTH EDUCATION

align with children’s best interests. Food systems are diverse, and so are the solutions,
but all food production and consumption must become sustainable if we are to protect
4 Mobilize supportive systems to scale up
nutrition results for all children
Bu

children’s nutrition today and tomorrow.

1
Empower families, children and young
people to demand nutritious food
1 in Drive
3 children
food suppliers to do
the right thing for children
is not growing well
2
3. Build healthy food environments for all children
1 Empower families, children and young
people
SOCIALto demand nutritious foodWATER &
PROTECTION SANITATION
Drive food suppliers to do
the right thing for children 2
5
18% 1%
Collect, analyse and use quality data and evidence
regularly to guide action and track progress

The personal and external food environments are where children and their caregivers SOCIAL
PROTECTION
WATER &
SANITATION
FOOD 18% 1%

interact with the food system. While the forces of supply and demand shape food
environments, context-appropriate actions such as mandatory front-of-pack labelling and HEALTH EDUCATION
FOOD

protection against exploitative marketing practices can help create foodMobilize

are conducive to nutritious diets for children.
environments
4 that
supportive systems to scale up
nutrition results for all children
HEALTH EDUCATION
Build healthy food environments
for all children 3
4 3
1
Mobilize supportive systems to scale up Build healthy food environments
nutrition results for all children for all children
Empower families, children and young
people to demand nutritious food
4. Mobilize supportive systems to scale up nutrition results for every child

As well as food systems, four other key systems must be mobilized to deliver nutrition
5
SOCIAL WATER &
Collect, analyse and use quality data and evidence PROTECTION SANITATION
regularly to guide action and track progress
services, improve nutrition practices and achieve nutrition outcomes at scale. The health,
water and sanitation, education and social protection systems must all Collect,
deliver
in a coordinated fashion. A systems approach to children's nutrition can help ensure that
5
analyseinterventions
and use quality data and evidence
regularly to guide action and track progress
FOOD

children and families have access to healthy diets and that children receive the nutrition
HEALTH EDUCATION
services they need to develop to their full potential.

4 Mobilize supportive systems to scale up

nutrition results for all children

5 | Collect, analyse and use good-quality data and evidence regularly to guide
action and track progress

Lack of adequate data prevents governments from responding with effective policies, strategies
and programmes. Accurate and timely data are needed to understand malnutrition, take
coordinated, evidence-based action, and to hold all actors to account. Data collection
methods and frequency must be transformed to expand what we know about the diets
5 Collect, analyse and use quality data and evidence
regularly to guide action and track progress

and nutrition of children, adolescents and women at every stage of life. Data systems must
become responsive and a culture of data-sharing and transparency must be developed.
What do young people think about food and nutrition?
More than 150,000 adolescents and
Where do you mostly eat?
young people in over 35 countries told
U-Reporters mostly eat at home with family
UNICEF’s U-Report about their attitudes
towards food, nutrition and body image. Outside
with friends
U-Report is an innovative social messaging
13
tool used by more than 7 million young
people around the world to share their
at
views on a range of common concerns. 59 Eat
home
By
All numbers refer to the percentage of respondents. myself 28
(Numbers may not add up to 100% due to rounding)

Do you eat healthily? Older U-Reporters are more likely to eat alone

Most U-Reporters, especially in low- Eat at 72

income countries, say they eat healthily home
55

By 17
myself
31
Outside 10
with
13–17 years old
friends 14 18–24 years old

Eating with the family means eating healthier

Outside
with friends
9

By
myself 23 67 Eat
home
at

72 61 48 55
Low Lower Upper High
income middle middle income Of U-Reporters who say they eat healthily more than 2
income income out of 3 say they mostly eat at home with their families
 < https://ureport.in >

What is the most important factor What’s stopping you

when deciding what to eat? from eating healthier?

Healthiness is the main concern in low- “Healthier food is often expensive, so

and lower-middle-income countries my family can’t afford it.”
 Female, 16, Eswatini
Cost
11
“Because my father has no means
Convenience 13 and I am a student of the 11th grade
sciences.”
50 Healthy  Male, 17 Mali

Taste 26
“Nutritious food is quite costly and
scarce.”
  Female, 23, India

But taste comes first in upper-middle and high-

income countries
“Can't buy healthy food because I
can't afford it. We'll eat vegetables
and fruits sometimes but it's just so
expensive to buy it every day.”
  Female, 21, Philippines

Bodyweight is also a concern in food choices

“Not enough time to cook, lack of
13–17 years old really fresh and useful products on
Females 15 18–24 years old store shelves.”
Males  8   Female, 19, Ukraine

Females 45
“Unhealthy foods are unfortunately
Males 50 tasty.”
  Male, 16, Brazil

Older U-Reporters are more likely to say weight is a

relevant factor in food choices “Because of the appearance and taste
of [healthy] food. It does not look
In high-income countries, weight is a concern for around colorful and is tasteless.”
3 out of 5 females but only for around 1 in 2 males.   Male, 18, Thailand
26 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

What do young people think

about healthy eating?
More than 450 young people in 18 countries took part in The State of the World’s Children 2019 workshops
to talk about what they eat and why. The workshops were held along with similar events for mothers (see
page 29). For a note on the workshop methodology, see page 178. Here we present an initial analysis of what
participants in 12 countries said about the obstacles to eating healthily and how they try to improve their diets. A
full analysis will be published in 2020. Responses have been translated and edited for clarity where necessary.

Do young people know which foods are healthy?

Overall, the adolescents who participated in the workshops reported making more healthy than unhealthy food
choices.115 After describing what they ate over a 24-hour period, they were asked to rate whether the items were healthy
or unhealthy. Their assessments were accurate for around half of the items, but inaccurate for about a fifth. For just
under a third of the items, they were unable to say whether the choice was healthy or unhealthy. Overall, adolescents
appear to have a limited understanding of the nutritional qualities of over half the foods they commonly encounter.

What prevents young people from eating healthily?

Adolescents said they faced significant barriers to Many adolescents reported that nutritious foods
healthy eating. Cost and taste were top of the list: were not sold near their homes:

“We lack money here to stay healthy … Our family is “Meat is not available. We have money to buy meat, but
unable to find good jobs.” Girl, 16, India the place is too far away.” Girl, 14, Ghana
“Some of the food is hard to afford.” Boy, 16, Zimbabwe “Unhealthy food is easier to come by.” Boy, 17, USA

Many perceived healthy foods to be more expensive:

“Cheap food is not healthy, and healthy food is not
cheap.” Girl, 13, China
Taste was another barrier:
“I really like junk food.” Girl, 14, Guatemala
“Healthy food is mainly not delicious.” Girl, 14, Kyrgyzstan
Taste was a particularly relevant factor for urban
participants. Some suggested that their food
preferences had been affected by the ready
availability of junk food:
“We are not able to eat healthy food because we have
already tasted junk food and are now attracted to that
only.” Boy, 14, India
Access and affordability were acute issues for some. In
the Sudan, adolescents in a refugee camp were nearly
three times more likely than rural participants to identify
cost as a barrier to healthy eating. Lack of access to
healthy food was also a key barrier.
The workshop participants pointed to the role of
parents and caregivers in determining what they
eat. They also highlighted time constraints for both
themselves and their parents:
“My choice of food is not prepared for me. My parents
decide what we will eat.” Girl, 15, Ghana
“Sometimes, there is no time to cook so I eat fast food.”
Girl, 15, Guatemala
“Mothers do not have time.” Boy, 14, Mexico

How do adolescents try to improve their own diets?
Young people from all the countries
surveyed reported taking personal action to
eat better. Many said they valued eating well
and set themselves personal goals:
“I remind myself to prioritize my health for at
least one meal a day.” Girl, 18, USA
“I try to make a better plan of what I’m going
to do during the day to avoid those types of
[unhealthy] food.” Girl, 15, Serbia
Adolescents generally understood that some
foodstuffs are not healthy, and took active
steps to eat less unhealthy food:
“I avoid the things that will affect me too much
... junk food and street food.”
Philippines, age and gender not indicated
“I arrange time properly to have enough time
to eat and start cooking for myself.”
Girl, 13, China
Sometimes they avoid unhealthy food by
distracting themselves:
“If I get tempted to binge, I’ll go for a walk,
take a nap, or call a friend or talk to my mom.
I think about how I’m going to feel later.”
Girl, 17, USA
I N T RO D U C T I O N | G ROW I N G W E L L I N A C H A N G I N G WO R L D » 27
© UNICEF/Escobar/2019
Some said they ate foods they regarded as
healthy even if they were not very tasty:
“I can tolerate the bad taste for the sake of my
health.” Girl, 17, Egypt
In lower-middle-income countries, gaining
work was an important response to the high
cost of food:
“Since there is no money to buy food, I have to
... work ... in order to get the money to buy it.”
Boy, 14, Ghana
“If I work ... to have money, then I will buy
food for my family.” Boy, 13, the Sudan
Saving money and eating home-grown and
home-cooked food were other solutions:
“Sometimes I save some money during the
week so that I can buy healthy food.”
Girl, 16, Serbia
“I … plant fruits and vegetables.”
Boy, 15, Guatemala
28 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

©UNICEF/China/2019/Ma Yuyuan

Summary What ideas do young people have to improve nutrition?

Large numbers
of adolescents Workshop participants highlighted the need “We need community leaders to talk to
value healthy for increased knowledge and awareness parents.” Group response, Ghana
eating and go to about diet and nutrition: “Prevent [the] selling of unsafe food.”
some lengths Group response, Serbia
to improve “Educate people. Urge people to eat healthy
meals. Hold meetings at the village library.” … as do young people:
their own diets.
Group response, Egypt
However, many “Form cooperative youth groups that deal with
face significant “Become informed through newspapers and food issues and health.”
obstacles, the internet and purchase food accordingly.” Group response, Zimbabwe
Boy, 13, China
notably cost “We can spread ... the awareness necessary
and access to to solve problems. And write banners. We
healthy food. They said governments, institutions and can create WhatsApp groups dedicated to
community leaders had a big role to play … solving problems.” Group response, Egypt
 I N T RO D U C T I O N | G ROW I N G W E L L I N A C H A N G I N G WO R L D » 29

What feeding challenges

do mothers face?
More than 320 women in 18 countries took part in The State of the World’s Children 2019 workshops to talk about
how they feed their babies and themselves. The workshops, organized with UNICEF country offices and national
committees and Western Sydney University (WSU), were held along with similar events for young people (see page
26). For a note on the workshop methodology, see page 178. Here we present an initial analysis of what participants in
12 countries said about their infant feeding practices and the barriers they face in feeding their children and themselves
well. A full analysis will be published in 2020. Responses have been translated and edited for clarity where necessary.

What are mothers’ infant-feeding practices?

The World Health Organization recommends that babies be exclusively breastfed for their first 6 months of life,
and then introduced to first (or complementary) foods, which gradually replace breastmilk between the ages of 6
and 23 months. Results from the workshop suggest that feeding practices in many instances are not optimal.

Almost all of the women breastfed either from birth or within the first 10 days after birth.116 However, around two
out of five mothers introduced breastmilk substitutes (BMS) by the time their baby was 8 weeks old, and most
were combining breastmilk and BMS (and, often, other liquids) before their baby reached 6 months of age.

Most mothers introduced first foods at 6 months of age, but a fifth started before their baby was 5 months old.
Some waited until the baby was between 7 and 9 months.

What barriers do mothers face in feeding their babies well?

Overwhelmingly, the main barrier to feeding babies
healthily was financial:
“I cannot even afford to give my baby unhealthy foods
as I do not have the money.” Age 20, Zimbabwe
“Money. I am not able to buy food to feed the child.”
Age 25, India
“There is no money at home.” Age 24, Ghana
Mothers often echoed the perception of a 38-year-old
workshop participant in the United States, who said,
“Healthy food is expensive.”
“In Australia, many things are expensive, like fish
… vegetables and meat. It should be cheap so that
anyone can buy it.” Age 29, Australia
“Sometimes, some foods are expensive.”
Age 22, Mexico
Access and availability are also obstacles:
“Sometimes healthy food is not available in the
house.” Age 28, Egypt
“It is difficult to get a vehicle to go … to buy food.”
Age 30, Ghana
“It is hard to get fruits and vegetables, melon,
watermelon, cucumber, carrot.”
Age 22, Guatemala
Mothers reported feeding challenges when babies
disliked certain foods, or were ‘fussy’ or sickly.
“My baby doesn’t like healthy food.” Age 24, Egypt
“Children do not want to eat healthy food – they
pester us, they start crying.” Age 25, India
“[I find it difficult to find] food that my child wants; my
child does not accept a particular type of food.”
Age 29, Sudan
30 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
© UNICEF/Baddoo/2019
“My child does not like to suck my nipple.”
Age 29, China
“When baby is not feeling well, when the
baby is teething, it makes it difficult to feed.”
Age 20, Ghana
What barriers do mothers face in feeding themselves well?
Just as with their babies, mothers reported cost
as the biggest barrier to their own efforts to eat
healthily, followed by accessibility and availability:
“Lack of money … if I had money, I would purchase
and prepare food as a mother [should].”
Age 25, Guatemala
“Sometimes I am short of money to buy some healthy
foods.” Age 25, Kyrgyzstan
Mothers also reported having to cope with
unwanted family advice:
“My mother-in-law wants to feed my 8-month-old
congee [a type of rice porridge] every day because
these are easy-to-digest foods. I want the child to
have all kinds of food.” Age 27, China
“My husband’s grandmother tells me what to feed him
[my baby].” Age not specified, Mexico
“I eat healthy food when it is available. When it’s not, I
eat whatever is available.” Age 20, Zimbabwe
“It is easier to acquire other foods [as opposed to
healthy foods].” Age 19, Mexico
“It’s a long distance from market to house.”
Age 26, the Sudan
 I N T RO D U C T I O N | G ROW I N G W E L L I N A C H A N G I N G WO R L D » 31

What are mothers’ solutions to the barriers they face?

Summary
Mothers identified a range of creative “I put mashed vegetables in the porridge Cost is by far the
workarounds to the barriers they face and feed when the child talks.” biggest obstacle
in feeding babies and themselves, Age 35, China to feeding and
including earning extra income and “I blend the fruit and put it in the cake... eating healthily
growing food themselves: I mix it with some food that she likes.” for mothers,
Age 25, Serbia followed by a lack
“We can farm maize and sell it to get of availability and
money; grow vegetables and sell to get To cope with unwanted advice from access to healthy
money; sell cell phones for money; sell foods. Many
members of the family, women
clothes for money.” Age 20, Zimbabwe
mostly said they tried to just ignore it, mothers described
“We can grow the food.” although this was not always possible: a range of other
Age 26, Zimbabwe challenges, including
“My mother told me to give my one- babies’ dislike
To overcome children’s food week-old baby some porridge, but I of certain foods,
preferences and ‘fussiness’, they ignored her.” Age not specified, Australia
‘fussy’ eaters and
described a range of creative solutions: “My mother-in-law constantly said I did family pressure.
not have enough milk, and in the end I
“I let her watch cartoons, rattle with stopped breastfeeding.”
toys, try to amuse her during the Age not specified, Australia
feeding.” Age 34, Serbia
32 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
PERSPECTIVE
Upholding a child’s right to food and nutrition
Hilal Elver
United Nations
Special Rapporteur
on the
Right to Food
Since 2014, Hilal Elver
has served as the Special
Rapporteur on the right
to food, responsible for
carrying out the right to food
mandate, as prescribed by
the United Nations Human
Rights Council. Hilal Elver is
an international law professor
and a Global Distinguished
Fellow at the UCLA Law
School’s Resnick Center
for Food Law and Policy;
she is also a research
professor at the UC, Santa
Barbara, where she has
been Distinguished Visiting
Professor since 2002.
It should concern us all that so many
children around the world suffer from
malnutrition in all its forms. This situation
demands a determined and effective
policy response – a response that can
only come about if there is political will
to protect and respect children’s human
rights, notably the right to adequate food,
which guarantees freedom from hunger,
and includes nutrition as a critical element.
Safeguarding this right requires states to
ensure that everyone – including children
– has access to food that, at the very least,
meets their basic nutritional needs and is
culturally appropriate and safe.
States also need to respond to the
structural and root causes of hunger
and malnutrition from a human rights
perspective. This should be guided by the
principle that children’s economic, social
and cultural rights are indivisible, a princi-
ple that underpins the Convention on the
Rights of the Child (CRC), which marks its
30th anniversary this year. Nowhere is this
indivisibility more relevant than in nutrition:
the rights to clean water, health and an
adequate standard of living, for example,
are preconditions for the full realization of
the right to food.
Similarly, the CRC extends additional
protections to children to ensure their right
to enjoy the highest attainable standard
of health. For example, it calls on states
to take measures to combat disease and
malnutrition by, among other actions,
providing adequate nutritious foods, as
well as nutrition information and education.
Children also have rights to social protec-
tion, to an adequate standard of living, and
to non-discrimination. This last principle is
especially important for protecting adoles-
cent girls from gender discrimination and
violence, and for preventing discrimination
against children of indigenous and rural
communities.
Even short-term hunger can harm a
child’s development. The CRC recog-
nizes this unique vulnerability across
the life course: it refers to the need to
support those responsible for children’s
care and to provide appropriate ante- and
post-natal healthcare for mothers. This is
supplemented by the Convention on the
Elimination of All Forms of Discrimina-
tion Against Women, which promulgates
rights for women during pregnancy and
lactation. Unfortunately, that Convention
falls short of protecting women’s individ-
ual right to adequate food and nutrition
beyond their capacit y as mothers.
Granting women the autonomy to make
everyday choices and the freedom to
e nj oy fu n d a m e nt al r i g ht s h a s b e e n
proven to improve reproductive health,
family nutrition and child welfare.
Over the years, the Committee on the
Rights of the Child has issued several
General Comments to help states imple-
ment policies. General Comment No. 15,
for example, emphasizes social protection,
 I N T RO D U C T I O N | G ROW I N G W E L L I N A C H A N G I N G WO R L D » P E R S P E C T I V E » 3 3
school-feeding programmes and preventive meas-
ures to avoid all forms of malnutrition. It also calls
upon states to limit children’s exposure to harmful
food advertisements, and calls upon private com-
panies to comply with the International Code of
Marketing of Breast-milk Substitutes and relevant
World Health Assembly resolutions.
In considering the importance of breastfeeding,
General Comment No. 7 advocates its promo-
tion and protection, endorsing the World Health
Organization’s recommendations on exclusive
breastfeeding. Nevertheless, many working moth-
ers still face considerable obstacles in fulfilling this,
in part because governments often fail to provide
adequate maternity leave to protect both mothers
and children.
Other General Comments cover the impact of
private sector activities on the natural resources
required to produce adequate food (No. 16), and the
particular risks of malnutrition among children who
are living with HIV/AIDS (No. 3). Also worth noting
is General Comment No. 11, which, along with the
Declaration on the Rights of Indigenous Peoples,
focuses on indigenous children, for whom the
© UNICEF/UN0315970/Pirozzi
cultural significance of traditional land and the qual-
ity of the natural environment are intrinsically linked
to the right to life and survival. A human-rights-
based approach to child nutrition requires a clear
understanding of the link between environmental
degradation, access to natural resources and the
rights of children to food and nutrition.
Integrating these human rights instruments and
soft law documents, such as the Voluntary Guide-
lines to Support the Progressive Realization of the
Right to Adequate Food in the Context of National
Food Security, into policymaking will ensure that
rural children, children of migrants, refugees, and
internally displaced peoples, as well as children
affected by conflict and climate change, are not for-
gotten, and will help states to guarantee the right
to food and nutrition in even the most marginalized
communities. Applying a human-rights-based
approach to the child’s right to food and nutrition
in a holistic manner requires good governance and
political will at national and international levels.
Once this political will is garnered, improving
participation, accountability, monitoring and trans-
parency are the first steps to implementing human
rights principles effectively.¢
01
CHILD
  MALNUTRITION
TODAY
 0 1 | C H I L D M A L N U T R I T I O N T O D AY » 35

Globally, almost 200 million children under †† Far too many children
continue to be affected
by undernutrition
5 suffer from stunting, wasting, or both and and hidden hunger,
while the numbers
at least 340 million from the hidden hunger who are overweight
are rising rapidly.
of vitamin and mineral deficiencies. At the
†† Malnutrition is both a
result, and a significant
same time, 40 million children under 5 are cause, of poverty
and deprivation.
overweight and the toll from overweight and
†† Food systems offer
obesity keeps rising, even in lower-income a range of significant
entry points to improve
countries. These patterns reflect a profound children’s nutrition.

†† Investment in nutrition
triple burden of malnutrition that threatens brings high returns and is
key to meeting the SDGs.
the survival, growth and development of
children and of nations.

A village health worker feeds micronutrients powder to a child in Liping County, Guizhou Province, China.
©UNICEF/China/2016/Xia Yong
36 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
All three strands Introduction
of malnutrition
– undernutrition, In the 21st century, children’s malnutrition
hidden hunger and has three key strands. The first is the
overweight – are continuing scourge of undernutrition.
interwoven Despite declines in some parts of the
world, undernutrition deprives far too
many children of the energy and nutrients
they need to grow well and is linked to just
under half of all deaths of children aged
under 5 each year.1 The second strand is
hidden hunger – deficiencies in essential
vitamins and minerals such as vitamins
A and B, and iron and zinc. Unseen, and
all too often ignored, hidden hunger
robs children of their health and vitality
and even their lives. The third strand is
overweight and, in its more severe form,
obesity. Once regarded as a condition of
the rich, overweight now afflicts more
and more children, even in some of the
world’s least-developed countries. It is
also fuelling a rise in diet-related non-
communicable diseases (NCDs) later in
life, such as heart disease, which is the
leading cause of death worldwide.2
All three strands of malnutrition –
undernutrition, hidden hunger and
overweight – are interwoven. They can
affect children, families and communities
simultaneously and over the course of
a single lifetime. The consequences are
profound, not just for the child’s own
prospects – in childhood itself and on into
adulthood – but also for national economic
development and the attainment of the
Sustainable Development Goals (SDGs).
These forms of malnutrition also share
many common causes. These begin
with the diets of children and mothers,
and stretch out to the ways in which
access, affordability and decision-
making power are distributed across our
societies. Increasingly, we cannot think
about the roots of these three strands
of malnutrition without talking about
food systems – everything that happens
to bring food ‘from farm to mouth’.
Children’s malnutrition in the 21st century
increasingly reflects the reality that too
many food systems provide children with
too little of the food they do need, and
too much of the food they don’t need.
Child malnutrition today
Undernutrition – stunting and wasting
Undernutrition profoundly affects
how children survive, grow and
develop. Two of its most important
forms are stunting and wasting.
Stunting
Stunting is used to describe populations
of children who are too short for their
age. But stunting is about far more
than the height of an individual child
– every community has shorter and
taller children. Rather, it is a stark sign
that children in a community are not
developing well, physically and mentally,
particularly in the first 1,000 days.
Stunting has been described as not just
the “best overall indicator” of children’s
well-being, but also an “accurate
reflection” of inequality in societies.3
As one report has noted, stunting “is
both a symptom of past deprivation
and a predictor of future poverty.”4
Sadly, in many communities, especially
where short stature is common, the
extent to which children are stunted is not
fully recognized.5 Because of its lifelong
consequences for children’s development,
such failures are serious, not just for the
well-being of individual children, but for
broader economic and social development.
 0 1 | C H I L D M A L N U T R I T I O N T O D AY » 37

Where do stunted children live?

FIGURE 1.1 | Percentage of stunted children under 5, 2018

GLOBAL TOTAL STUNTED

21.9% (149 million)

Eastern Europe
and Central Asia
9.0%

North America
2.6% East Asia
and the Pacific
8.4%
Middle
East and
West and North Africa
Central Africa 14.7%
33.1% South Asia
34.4%

Eastern and
Southern Africa
Latin America 33.6%
and the Caribbean
9.0%

%
No data No current data <2.5 2.5 – <10 10 – <20 20 – <30 ≥30
(very low) (low) (medium) (high) (very high)

%
South Asia 34.4
Eastern and Southern Africa 33.6 In South Asia and sub-
West and Central Africa 33.1
Saharan Africa, 1 in 3
Middle East and North Africa 14.7
Eastern Europe and Central Asia 9.0 children under five
Latin America and the Caribbean 9.0 is stunted
East Asia and the Pacific 8.4
North America 2.6

Note: Country data are the most recent available estimate between 2000 and 2018; where only data prior to 2000 are available, the dark grey color denoting no recent data is used. The
designations employed in this publication and the presentation of the material do not imply on the part of the United Nations Children’s Fund (UNICEF) the expression of any opinion
whatsoever concerning the legal status of any country or territory, or of its authorities or the delimitations of its frontiers.
Source: UNICEF/World Health Organization/World Bank Group Joint Malnutrition Estimates, 2019 edition.
38 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Despite the
encouraging
declines in stunting,
most parts of the
world are currently
not on course to
meet targets for the
SDG era
In Pakistan, six-year-old
Mudassir’s height is measured in
a nutrition screening session.
© UNICEF/UN048378/Pirozzi
As with other forms of malnutrition,
the causes of stunting start with the
nutritional status of the mother. Mothers
who suffered stunting in childhood
are at greater risk of having stunted
children. Women who are short of
stature are also at greater risk of giving
birth to pre-term children or children
of low birthweight, who are, in turn,
more likely to go on to be stunted. In
2015, an estimated 14.6 per cent of
newborns had low birthweight, and
about 9 out of 10 of these infants were
in low- and middle-income countries.6
Stunting can thus be perpetuated across
generations and, because of its close
link to deprivation, can transmit poverty
from one generation to the next.
This cycle can be broken. In just a single
generation, women malnourished
in childhood but who subsequently
experience substantial improvements in
their health, nutrition and living environment
before conceiving can have children who
are close to normal height.7 Evidence
such as this underscores the importance
of investing in maternal nutrition, not
just to raise the life prospects of women,
but also those of the next generation.
After a child is born, the nutritional status
of the mother continues to be a factor
through breastfeeding (see Chapter 2).
Other factors also influence the child’s
development, including the extent to
which a child’s family has the resources
to offer adequate food and care and its
access to health services and clean water
and sanitation. Repeated infections and
gut inflammation can trap a child in a
vicious cycle of disease and malnutrition:
for example, a child with an inflamed gut
finds it harder to absorb adequate nutrition,
which weakens the child’s resistance to
illness. It is estimated that a quarter of
all cases of stunting in children aged 2
and under can be attributed to the child
having experienced five or more cases
of diarrhoea.8 Combating stunting thus
requires investments in improving the
quality of children’s diets and related
nutrition practices and services.
Globally, the proportion and number
of stunted children under 5 has been
declining (see Figure 1.2). It fell by a
quarter between 2000 and 2018 to 149
million children. In broad terms, this
reflects rising incomes and improvements
in governance in many countries.9
However, despite worldwide declines,
progress in reducing stunting in much of
Africa has been slow. Indeed, reflecting
strong population growth, two UNICEF
regions in the continent actually saw
increases in the numbers of children
affected between 2000 and 2018: the
number of children under 5 with stunting
rose by 1.4 million in Eastern and Southern
Africa and by 6.5 million in West and
Central Africa. The implications of this
continuing burden of stunting for Africa’s
human capital development are serious.
Despite the encouraging declines in
stunting, most parts of the world are
currently not on course to meet targets
for the SDG era. Similarly, targets for
wasting and overweight risk not being
met without a sustained effort. The
global reductions in stunting can also
mask the reality that, in many countries,
huge proportions of children still suffer
from stunting – around 38 per cent of
under-5s in India and Pakistan and 43 per
cent in the Democratic Republic of the
Congo.10 Even these national statistics
paint only a partial picture. Within
countries, there can be major differences
between regions. In India, for example,
almost half of children are stunted in
the worst-affected state compared with
a fifth in the least-affected state.11
 40 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

FIGURE 1.2 | Projections for malnutrition in children under 5 compared to 2030 targets

%
39.2
The world is
40

35.5

32.5
not on course
30 29.3
to meet targets for
26.2
stunting, wasting
25.0
23.3 and overweight
21.1
19.2
20
21.9 proje
cted
17.5

12.2% 12.2% 2030 Target for stunting

10
7.3
6.0 6.3
projected
6.7

3% 4.8 4.84 4.9 5.1 5.45 5.5 5.7

5.9 3% 2030 Target for overweight
3% 2030 Target for wasting
0
2030
2018
1990

1995

2000

2005

2010
2012

2015

2020

2025

Notes: WHA 2030 targets are a) 50% reduction in the number of children under-5 who are stunted, b) Reduce and maintain childhood overweight to less than 3% and c) Reduce and maintain
childhood wasting to less than 3%. Wasting is an acute condition that can change frequently and rapidly over the course of a calendar year. This makes it difficult to generate reliable trends over time
with the input data available and, therefore, this report provides only the most recent global and regional estimates. https://data.unicef.org/resources/who-unicef-discussion-paper-nutrition-targets/
Source: UNICEF/World Health Organization/World Bank Group Joint Malnutrition Estimates, 2019 edition. Projections are based on analyses conducted by the UNICEF/World Health
Organization/World Bank Income Group Joint Malnutrition Estimates Working Group.

Wasting of worldwide deaths among under-

5s representing 875,000 child deaths
Wasting describes a child who is too that could have been prevented.12
thin for his or her height. With important
exceptions, it often reflects a recent Trends in wasting can shift rapidly and
Globally, wasting loss of weight arising from severely frequently in response to factors like
threatens the lives poor nutrient intake, illness or both. the seasonal availability of food and
of 7.3 per cent of the Globally, wasting threatens the lives disease patterns for diarrhoea and
world’s under-5s, or of 7.3 per cent of the world’s under- malaria. Nevertheless, there is concern
around 50 million 5s, or around 50 million children. In that the global declines seen in child
children 2013, wasting led to around 13 per cent stunting have not been seen in wasting.

This seems to be particularly true in
South Asia, a global epicentre for wasting,
where 15.2 per cent of under-5s are
affected, a proportion that international
agencies class as ‘high’13 (other hotspots
include sub-Saharan Africa, Southeast
Asia and Oceania – see Figure 1.3), and
where rates of wasting have shown
little improvement.14 South Asia is also
notable for when wasting occurs in a
child’s life. Wasting in the region is most
widespread in the first year of the child’s
life, and less so in later childhood. In
effect, many wasted children appear to
be born wasted.15 This has important
implications for solving the problem of
wasting (as well as stunting) in the region:
it clearly supports a strong prevention
approach, particularly in supporting the
nutrition of adolescent girls and mothers,
and encouraging improved infant
feeding and hygiene practices in the
first two years of life (see Chapter 3).16
BOX 1.1 | Caring for wasted children at home
Recent years have brought significant breakthroughs in
the treatment of SAM, notably with the rolling out of
community management of acute malnutrition (CMAM)
in many countries. Before CMAM, children with SAM were
typically referred for lengthy and expensive in-patient
hospital stays, a burden on many families that contributed
to low rates of treatment. The CMAM approach instead
empowers families to treat SAM at home, usually with
ready-to-use therapeutic foods (RUTF) for children without
medical complications, which comprise the majority of cases.
August 13, 2016 September 20 2016 December 2016 September 2017
Weight: 3.3 kg Weight: 4.6 kg Weight: 6+ kg
0 1 | C H I L D M A L N U T R I T I O N T O D AY » 41
Wasting – the more widespread form of Wasting can
acute malnutrition – can be devastating be devastating
for children, particularly in its most for children,
serious forms. Left untreated, children particularly in its
with severe acute malnutrition (SAM) most severe forms
are nearly 12 times more likely to die
than a healthy child.17 SAM often results
from a rapid deterioration in nutritional
status, and is typically characterized by
wasting, extreme thinness, or the swelling
that is typical of nutritional oedema.18, 19
While the risk of death associated with
SAM is highest for under-5s, school-age
children and adolescents are also at risk.
Children who appear to recover from SAM
can still suffer cognitive impairments
and other developmental problems,
especially if they have stunted growth.20
Global rates of severe wasting remain
high: in 2018, around 16.6 million
children under 5 were estimated to
suffer from it.21 As with other forms of
This approach has improved survival rates and has proved
highly cost-effective, although more needs to be done to
lower costs, for example through local production of RUTF).27
While management of SAM is among the 10 highest impact
nutritional interventions to reduce child mortality,28 this
impact can potentially be boosted still further: For example,
health services that provide early detection of both SAM
and HIV can be critical in improving survival rates among
children by facilitating interventions at a critical point in
disease progression and child development.¢
Born in the rural Philippine province of Palawan, Joemar comes from a deprived
family in which both parents have suffered health problems. The family’s ethnic
community has limited access to services and understanding of malnutrition.
As a result, and despite showing clear symptoms, Joemar was not immediately
diagnosed as suffering from severe acute malnutrition. Once treatment began,
he made swift progress, doubling his weight in just a few months. Just like
Joemar, more Filipino children are now getting a second chance: Supported
by UNICEF, the Philippines is scaling up services and capacities to prevent
and treat acute malnutrition and, by 2022, aims to put in place a nationwide
programme of interventions, with a strategic focus on the first 1,000 days.
© UNICEF/Philippines/2016
Weight: 9 kg
42 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

Where do wasted children live?

FIGURE 1.3 | Percentage of wasted children under 5, 2018

GLOBAL TOTAL WASTED

7.3% (49.5 million)

Eastern Europe
and Central Asia
2.0%

North America
0.4%
East Asia
and the Pacific
2.9%
Middle
East and
North Africa
West and 7.7%
Central Africa
9.0% South Asia
15.2%

Eastern and
Latin America
Southern Africa
and the Caribbean
6.2%
1.3%

%
No data No recent data < 2.5 2.5 – <5 5 – <10 10 – <15 ≥15
(very low) (low) (medium) (high) (very high)

%
South Asia 15.2
West and Central Africa 9.0
Middle East and North Africa 7.7
Eastern and Southern Africa 6.2
East Asia and the Pacific 2.9
Eastern Europe and Central Asia 2.0
Latin America and the Caribbean 1.3
In South Asia more than 1 in 7
North America 0.4 children under 5 is wasted

Note: Country data are the most recent available estimate between 2000 and 2018; where only data prior to 2000 are available, the dark grey color denoting no recent data is used. The
designations employed in this publication and the presentation of the material do not imply on the part of the United Nations Children’s Fund (UNICEF) the expression of any opinion
whatsoever concerning the legal status of any country or territory, or of its authorities or the delimitations of its frontiers.
Source: UNICEF/World Health Organization/World Bank Group Joint Malnutrition Estimates, 2019 edition.

malnutrition, poverty is often at the heart
of SAM. Seasonal fluctuations matter,
too: the rainy season is often the pre-
harvest period when food stocks are low,
roads are cut off, and the incidence of
waterborne disease increases. Children
who are ill are also at particular risk:
those with HIV are three times as likely
to die from SAM as their counterparts.
22, 23, 24
HIV together with malnutrition
among infants is particularly fatal.
Although children suffering SAM
are often the face of humanitarian
emergencies, most SAM cases actually
occur in non-emergency settings. The
mistaken assumption that SAM mainly
occurs in emergencies – and is the
responsibility of the humanitarian
0 1 | C H I L D M A L N U T R I T I O N T O D AY » 43
A girl receives Vitamin A drops at Mont
community – has hampered effective
Ngafula Health Centre in Kinshasha,
prevention and treatment of SAM globally. Democratic Republic of Congo. Vitamin
A deficiency is the leading cause of
preventable childhood blindness and
Overall, far too few children with SAM increases the risk of death from common
childhood illnesses such as diarrhoea.
are being treated. Despite global progress Despite the increasing availability of
in the number of children reached fortified foods, about one in five children
is deficient in vitamin A.41 © UNICEF/
(from 1.1 million children in 2009 to 4.4 UNI44415/Pirozzi
million in 2017), only about one in four
children receives treatment.25 Scaling up
successful approaches requires supportive
national policies, dedicated government
resources and integration into routine
national services. In countries where
this has been achieved, efficiency and
scale-up have been greatly increased.26
Even so, although treatment saves lives,
it does not address the underlying and
basic causes that are key to ensuring
the long-term prevention of wasting.
44 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

Where do children with hidden hunger live?

FIGURE 1.4 | Percentage of children under 5 with hidden hunger

76

69
67
64 64

51
47
46 46

The Americas and the Caribbean

41
37 36
33
31
27
21
19 19

GLOBAL
11

Oceania
Europe
Africa

Asia

Middle Eastern Western Southern Northern South- South- Western Eastern Eastern Southern Northern Western Caribbean Central South Northern Oceania GLOBAL
Africa Africa Africa Africa Africa Central Eastern Asia Asia Europe Europe Europe Europe America America America
Asia Asia

%
<25 25 – 49.9 50 – 74.9 >75

Source: UNICEF estimates, 2019 based on Black et al, 2013 and Stevens et al, 2015. See Note on Figures on p. 179 for more information.

At least 340 million Hidden hunger ability to learn.31 UNICEF estimates that
children under 5 (one globally, at least one in two children
in two) suffer from Children and mothers who are deficient under 5 – or 340 million – suffers from
hidden hunger in micronutrients – the vitamins and hidden hunger due to deficiencies in
minerals that are essential for survival, vitamins and other essential nutrients.32
growth and development – can suffer
devastating consequences. Some Often, however, the effects are
examples: vitamin A deficiency is the invisible or may appear too late for
main cause of blindness in children.29 anything to be done. That’s why these
Women with severe anaemia (often, deficiencies are often referred to as
although not exclusively, linked to a lack ‘hidden hunger’. Hidden or not, the
of iron in the diet) have double the risk impact is very real. As UNICEF’s Kul
of dying during or shortly after childbirth C. Gautam said in 2004, “You might
(see Figure 1.4).30 Iodine deficiency, even not feel it in the belly, but it strikes at
in its mild forms, can harm a child’s the core of your health and vitality.”33

As with all forms of malnutrition, poor
diets play a major role in hidden hunger.
Indeed, dietary diversity is used as a
measure of whether or not children and
mothers are meeting their micronutrient
needs.34 These measures paint a worrying
picture (see Chapter 2). But children
and mothers also need to be physically
able to absorb vitamins and minerals.
Conditions such as diarrhoea and chronic
gut inflammations can prevent that from
happening, as can other factors, for
example whether a micronutrient comes
from an animal- or plant-source food.
More broadly, hidden hunger can exist
with both traditional and modern diets.
Some communities in low-income
countries, for example, depend heavily
on just a few staples, such as grains and
tubers, and may only very occasionally
eat more nutrient-rich items such as
fruit, vegetables, meat, fish, eggs and
dairy. Modern diets, too, are implicated.
Processed and ultra-processed foods can
be fortified with essential vitamins and
minerals, and in many parts of the world
this helps meet children’s micronutrient
needs (see Chapter 4). However, ultra-
processed foods and drinks can also
be deficient in essential vitamins and
minerals.35, 36 And because some of these
foods, such as cheap instant noodles
and biscuits, can be very filling, they
can reduce children’s appetite for more
nutrient-dense fruits and vegetables.37
Precise and up-to-date estimates of
the extent of hidden hunger are lacking,
reflecting the challenge, cost and time-
consuming nature of measuring it. Given
the seriousness of hidden hunger’s
impact on children, there is an urgent
need to improve understanding of the
problem through the development of
inexpensive and effective forms of testing.
UNICEF’s recent global estimate – of at
least 340 million children under 5 – is a
0 1 | C H I L D M A L N U T R I T I O N T O D AY » 45
conservative figure as it only reflects
the estimated number of children
who suffer from vitamin A and iron
deficiencies.38 In both high- and low-
income countries, children are at greatest
risk of hidden hunger and frequently suffer
multiple deficiencies simultaneously, a
reflection of their poor diet overall.39, 40
Overweight and obesity
Overweight and obesity matter for
children, both in childhood and in later
life. In childhood, they can lead to a
number of medical conditions, including
gastrointestinal, musculoskeletal and
orthopaedic complications, as well
as the early onset of type 2 diabetes
and behavioural and emotional
problems, including depression and
stigmatization. Childhood obesity
is also a strong predictor of adult
obesity, which can have serious health
and economic consequences.42
The number of overweight children has
increased in every continent (see Figure
1.5). Based on recent trends, the number
of overweight under-5s will rise from 40
million children to 43 million by 2025.43
Overweight is sometimes seen as a
problem only in wealthy countries, but
it is striking just how much it now
also affects low- and middle-income
countries and how rapidly the problem is
growing (see Figure 1.6). In 2018, almost
half the world’s overweight under-5s
lived in Asia and a quarter in Africa;
in Africa, the number of overweight Overweight is
under-5s rose by just under 44 per sometimes seen as
cent between 2000 and 2018.44 a problem only in
wealthy countries,
These data tell only part of the story, but it is striking just
however. Estimates for older children how much it now
help indicate the true scale of the also affects low-
overweight challenge. According to and middle-income
the NCD Risk Factor Collaboration, the countries
46 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

Where do overweight children live?

FIGURE 1.5 | Percentage of overweight children under 5, 2018

GLOBAL TOTAL OVERWEIGHT

40.1 million (5.9%)

Eastern Europe
and Central Asia
14.9%

*
North America
8.8%

East Asia
and the Pacific
6.3%
Middle
East and
North Africa
West and 11.2%
Central Africa
2.8% South Asia
3.1%

Latin America
and the Caribbean Eastern and
7.5% Southern Africa
4.2%

%
No data No current data <2.5 2.5 – <5 5 – <10 10 – <15 ≥15
(very low) (low) (medium) (high) (very high)

Eastern Europe and Central Asia 14.9%

Middle East and North Africa 11.2%
North America 8.8%
Latin America and the Caribbean 7.5%
East Asia and the Pacific 6.3%
Eastern and Southern Africa 4.2% In Eastern Europe and Central
South Asia 3.1% Asia, almost 1 in 7 children
West and Central Africa 2.8%
under 5 is overweight

Note: Country data are the most recent available estimate between 2000 and 2018; where only data prior to 2000 are available, the dark grey color denoting no recent data is used.
The designations employed in this publication and the presentation of the material do not imply on the part of the United Nations Children’s Fund (UNICEF) the expression of any
opinion whatsoever concerning the legal status of any country or territory, or of its authorities or the delimitations of its frontiers.
Source: UNICEF/World Health Organization/World Bank Group Joint Malnutrition Estimates, 2019 edition.
 0 1 | C H I L D M A L N U T R I T I O N T O D AY » 47

FIGURE 1.6 | Trend in percentage of countries by World Bank income group FIGURE 1.7 | Increase in overweight among under-5
where at least 10 per cent of children aged 5–19 years are overweight and 5–19-year-old children and young people

Low- and lower middle-income countries have seen a

significant rise in overweight over the past decade.

100 18.4
High-income countries
75
ars
ye
19
Upper-middle-income countries 5–
% 50

10.3
25 Lower-middle-income countries
%
Under 5 years
Low-income countries
5.9
0 5.5
1990

1995

2000

2005

2010

2015
2016

2018
2000
Note: Income classifications are based on World Bank FY19 classifications.
Source: NCD Risk Factor Collaboration (NCD-RisC) (2017). ‘Worldwide trends in body-mass index, underweight,
overweight, and obesity from 1975 to 2016: A pooled analysis of 2416 population-based measurement studies Source: UNICEF/World Health Organization/World Bank Group Joint
in 128·9 million children, adolescents, and adults’, The Lancet, 390(10113), pp. 2627–2642 Malnutrition Estimates and NCD Risk Factor Collaboration (2017).

proportion of overweight children

aged between 5 and 19 rose from
countries, albeit at very high levels –
around a third of children aged 2 to 15
Overweight
around 1 in 10 (10.3 per cent) in in the United Kingdom, for example.46 is no longer a
2000 to a little under 1 in 5 (18.4 However, this trend is not being seen
per cent) in 2016 (see Figure 1.7). in poorer communities, resulting problem just
What’s driving these increases?
in widening inequalities in rates of
obesity between high- and low-income
for wealthier
Research points to a few key factors. A social groups. Children from poorer countries
rising intake of calories, a shift in what backgrounds also tend to have more
children are eating from traditional severe forms of overweight.47, 48 In and is
to modern diets, urbanization and
falling levels of physical activity all
low- and middle-income countries,
and especially in much of Asia, rates
rising faster
play a part.45 Some research also of overweight look likely to go on among older
suggests that changes in the gut rising. Strikingly, there is little or no
microbiome may be a factor. consistent evidence of countries children
achieving and sustaining a decline
Where are childhood trends going? in obesity across the population
There are signs that overweight has since the 1980s,49 underlining the
been levelling off in high-income need to focus on prevention.
48 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

SPECIAL SECTION

Overweight and obesity

in OECD and EU countries

A century ago, overweight and obesity were linked to wealth. Not anymore. In
wealthy countries, poor children are often the most likely to be overweight or obese.50

Although rates of overweight in children have plateaued in many high-income

countries, they have nevertheless settled at levels that put millions of children’s lives,
health and futures at risk.51 Among 41 countries in the OECD and EU, not one has fewer
than one in five children (aged 5–19 years) overweight, except for Japan (see Figure 1.8).

Overweight and disadvantage Response

The children who suffer overweight are usually from
socio-economically disadvantaged families. In the
United States, for example, overweight in children
decreases as families’ education and income levels
increase.53 The link between obesity and socio-
economic disadvantage has also been demonstrated
in Europe.54 A study using data from the 2008 WHO
Childhood Obesity Surveillance Initiative in Europe
linked parental socio-economic status and lack
of education with obesity in children in Czechia,
Portugal and Sweden.55
The impact of overweight on lives and economies
offers a cautionary tale as these health risks rapidly
expand into low- and middle-income countries.56 The
effects are also economic. In Germany, the lifetime
cost of overweight and obesity – due to factors
including lost productivity and illness – is about 145
billion euros (about US$162 billion).58 In the United
States, US$190 billion a year is spent on treating
obesity and obesity-related conditions – about a
fifth of the country’s healthcare expenditures. In
Brazil’s public hospitals, the estimated direct costs
of diseases related to overweight and obesity were
US$2.1 billion annually.58
Despite growing awareness of the dangers
of overweight, efforts to address the issue
have not been systematic.59 In recent years,
however, countries including Belgium, Chile,
Finland, France, Hungary and Mexico have
begun to establish policies to address obesity,
including taxes and easy-to-understand
nutrition labels such as front-of-pack warning
labels. These and other efforts are guided by
WHO recommendations aimed at providing
a holistic approach to addressing childhood
obesity.60, 61, 62
Globally, there is little information on government
spending to address obesity and diet-related
NCDs, such as diabetes, cardiovascular
disease and some cancers.63 In 2015, only
about 0.01 per cent of global development
assistance was spent on preventing and
treating obesity- and diet-related NCDs.64 As
low- and middle-income countries begin to deal
with the complex consequences of growing
rates of overweight, the costs of prevention
and treatment risk exceeding the capabilities of
healthcare systems to respond.¢
 0 1 | C H I L D M A L N U T R I T I O N T O D AY » S P E C I A L S E C T I O N » 4 9

The children who

suffer from overweight
are usually from
socio-economically
disadvantaged families

FIGURE 1.8 | Percentage of children and adolescents 5–19 years who are overweight in 41 OECD and EU countries

Country Prevalence % Country Prevalence %

(%) increase (%) increase
2016 since 2016 since
1990 1990

United States 41.86 49.7 Croatia 28.00 160.0

New Zealand 39.46 44.6 Republic of Korea 27.63 94.9
Greece 37.26 48.9 Norway 27.47 42.1

Malta 37.11 20.1 Czechia 27.19 81.2

Italy 36.87 39.1 Slovenia 27.18 168.8

Chile 35.54 61.1 Finland 26.81 35.7

Mexico 35.51 76.0

Austria 26.68 48.8
Germany 26.58 37.0
Israel 34.80 18.2
Luxembourg 26.33 29.3
Australia 34.11 35.1
Poland 25.72 131.1
Spain 33.80 38.4
Denmark 25.11 13.6
Cyprus 33.47 50.6
Netherlands 24.77 61.9
Portugal 32.57 86.2
Romania 24.56 171
Canada 32.15 45.1
Belgium 23.93 -1.8
United Kingdom 31.12 33.1
Sweden 23.62 24.6
Ireland 30.86 84.4
Slovakia 23.36 157.0
France 30.09 38.7
Switzerland 21.87 39.4
Turkey 29.55 151.1
Latvia 21.33 75.9
Bulgaria 28.47 120.6 Lithuania 20.58 84.2
Hungary 28.45 117.3 Estonia 20.46 68.0
Iceland 28.33 15.3 Japan 14.42 14.3

Source: NCD Risk Factor Collaboration (2017).52

50 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

Undernutrtion, Pulling the strands of of malnutrition is the coexistence of

hidden hunger malnutrition together
and overweight
share common
causes, notably As noted earlier, the various strands of
the poor quality of malnutrition – undernutrition, hidden
children's diets hunger and overweight – are interwoven
in many different ways. For example, two
or three forms of malnutrition may strike
children simultaneously or across the
course of their lives. In addition, two, or
increasingly all three, are simultaneously
present in growing numbers of countries
and communities – a triple burden of
malnutrition (see Figure 1.9). Finally,
all three share many common causes,
notably the poor quality of children's diets.
stunting and wasting. As one group
of experts puts it, “a wasted child is
more likely to become stunted and a
stunted child is more likely to become
wasted.”65 Such children are likely to
have experienced “an early environment
characterized by harsh deprivation,” as
one study notes. 66 This combination of
stunting and wasting increases the risk of
death, even compared with children who
are severely wasted.67 Given these links,
there have been growing calls in recent
years for nutrition programmes to address
stunting and wasting simultaneously.
Failure to do so risks undermining the
effectiveness of programmes.68

Coexistence in individuals Other forms of coexistence also exist. For

example, 8.2 million children under 5 are
One of the most common ways in estimated to suffer from both stunting
which a child can suffer multiple forms and overweight globally while stunting,

FIGURE 1.9 | Number of countries with overlapping forms of childhood stunting, wasting, overweight and anaemia

How many 101 77 124 62

countries had at countries had at countries had countries had at

countries face a least a medium

stunting prevalence
least a medium
overweight prevalence
moderate anaemia
prevalence
least a medium
wasting prevalence

triple burden of Overweight only

malnutrition? 6 Anaemia only

4
Overweight Overweight Wasting and
and stunting and anaemia anaemia

Stunting only
1 18 1 Wasting only

1 Overweight,
stunting and
anaemia
Overweight,
wasting and
anaemia
0
27 3
Stunting,
wasting,
Note: A medium stunting prevalence is defined as
overweight
>10%; a medium overweight prevalence is defined as and anaemia
Stunting and Overweight

22
>5%; a medium wasting prevalence is defined as >5%; anaemia and wasting

14 0
a moderate anaemia prevalence is defined as >20%.
Analysis is based on 134 countries with recent estimates
for at least three indicators. Stunting,

Source: UNICEF, WHO, World Bank Group (2019). Joint

wasting and
anaemia 0
35
Child Malnutrition Estimates. WHO, Geneva. Source
for anaemia data: Global Health Observatory, World
Health Organization (2019). Anaemia in children <5 Stunting and
wasting
years – Estimates by country [Data table]. Retrieved
1
Overweight,
from http://apps.who.int/gho/data/view.main. stunting and
ANEMIACHILDRENREGv. wasting

wasting and overweight often coexist
with different forms of hidden hunger.69
Individuals can also suffer from different
forms of malnutrition across their lives: for
example, stunting in early childhood may
raise the risk of overweight in later life.70
The triple burden of malnutrition
Many parts of the world are now facing
the triple burden of malnutrition, which
is evident in countries, communities and
even individual families. One regularly
cited example is where a family has
an overweight mother and a stunted
child. In India, analysis of 2011–2012
data suggests this may be the case in 5
per cent of rural and 8 per cent of urban
households. For Egypt, the figure is
5.6 per cent of households, according
to analysis of 2008 data. In both
countries, the problem appears to be
growing.71 In Egypt, researchers attribute
part of the rise to families’ increased
consumption of sugary snacks, which
fail to provide children with the nutrients
they need for healthy growth and
provide excess calories to the mother.72
These examples highlight the need to
consider children’s malnutrition in the
wider family and household context.
More broadly, many low- and middle-
income countries are now facing the
challenge of coping with the continuing
burden of stunting and wasting, various
forms of hidden hunger and rising rates
of overweight (see Figure 1.9). For
many, these multiples challenges risk
outpacing their capacity to respond.
Poverty, exclusion and malnutrition
Poverty is often at the heart of malnutrition.
According to a 2016 UNICEF and World
Bank Study, of the 385 million children
living in extreme poverty around the
0 1 | C H I L D M A L N U T R I T I O N T O D AY » 51
world in 2013, half lived in sub-Saharan Poverty is often
Africa and just over a third in South at the heart of
Asia. More than four out of five of malnutrition … poor
these children lived in rural areas. They children are more
are more likely to be underfed and likely to be underfed
malnourished, get sick, not complete and malnourished,
school and fall back into poverty in get sick, not complete
the aftermath of drought, disease or school and fall back
economic instability. Poor children into poverty in the
are also least likely to have access to aftermath of drought,
safe water and adequate sanitation, to disease or economic
receive preventative healthcare such as instability
vaccinations, and when ill are less likely
to get adequate medical care. These
problems are experienced even more
intensely by children living through
emergencies and other crises (see
Special section: Nutrition in emergencies).
Poverty is about more than just financial
resources. For many children and families,
it is intertwined with social exclusion,
discrimination and marginalization driven
by gender, disability, ethnicity, geographic
remoteness and displacement. At the
individual level, such exclusion and
inequity determine local access to
goods and services, including healthy
foods. At the societal level, they can
mean that the voices and needs of poor
and marginalized communities are not
heard in broader decision-making.
The impact of gender is evident in every
facet of malnutrition and its causes (see
Chapter 3, Special section: Girls and
women need stronger support for better
nutrition). Research and programmatic
experience show that women’s
empowerment is associated with better
nutrition for children and women, yet
in far too many places, women are still
served last (and least) at mealtimes and
have very limited autonomy, which can
mean having limited or no control over
their own and their family’s income and
being excluded from making decisions.
52 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

Stigma around Disability can be both a cause and face greater risk of malnutrition.
disability can result consequence of malnutrition. A lack In Brazil, for example, the rate of
in newborns not of nutrients, vitamins and minerals, stunting among indigenous groups
being breastfed or or exposure to high levels of toxins, in 2013 was two to five times higher
children being given for example, can lead to blindness than among non-indigenous groups.
less nutritious or or neurological damage. At the Explanations for this difference
smaller portions same time, some disabilities – such include poorer nutrient intake,
of food as intellectual and developmental poorer sanitation and less access
disabilities or a cleft palate – can to primary healthcare services.73
lead to a reduced nutrient intake or
failure to meet increased nutritional Geographical remoteness can
needs. Stigma around disability also determine whether a family
can result in newborns not being has access to essential foods and
breastfed or children being given healthcare and nutrition services.
less nutritious or smaller portions of Compared with their urban
food, or even not being fed at all. counterparts, children living in rural
areas of Burundi, Honduras and Mali
Indigenous people and other are twice as likely to be stunted, which
disadvantaged ethnic groups also rises to three times as likely in Peru.74

FIGURE 1.10 | Percentage of stunted children in poorest vs. richest households in low-, lower-middle-, upper-middle- and high-income countries

70 High-income countries
Upper-middle-income countries

Lower-middle-income countries
60
Low-income countries
r
poo
in
g
tin
50 un
St
=
h
ric
in
ti ng
Poorest households (%)

n
tu
40

is
lin
e :S
Malnutrition
th
Al
on
g
is closely tied
30
to poverty
20

Notes: Analysis is based on a subset of 80

countries with available disaggregated data
on richest and poorest quintiles between
10 2012 and 2018.
Source: UNICEF, WHO and International
Bank for Reconstruction and Development/
World Bank. 2019. Levels and trends in child
malnutrition: Key Findings of 2019 Edition of
0 the Joint Child Malnutrition Estimates.
0 10 20 30 40 50 60 70

Richest households (%)


SPOTLIGHT
United Kingdom: Poorest children at greater risk of overweight and food insecurity
One in three children in England is overweight or
obese by the time they leave primary school.114 Over-
weight and obesity prevalence is more than twice as
high in the poorest areas, and the gap is widening as
obesity continues to rise in the most deprived areas.115
The picture is similar for children elsewhere in the Unit-
ed Kingdom.116
Children’s diets are heavily influenced by the environ-
ments in which they live. England’s poorest areas are
fast-food hotspots, with five times more outlets than
in the most affluent areas.117 Children from poorer are-
as are disproportionately exposed to takeaways selling
fried chicken, burgers and pizzas, and poorer areas also
have more visible advertising for unhealthy foods than
wealthier areas.118
The UK food retail environment encourages unhealthy
foods consumption. Up to 40 per cent of foods pur-
chased in supermarkets are on promotion, and unhealthy
foods are more likely to be promoted.119 Promotions have
been shown to increase the amount people buy, and lo-
cations such as end-of-aisle displays and checkouts are
frequently used to promote unhealthy foods.120
At the same time, nearly 2 million children in England
live in food poverty,121 and less than one-fifth of 5-to-
15-year-olds eat five portions of fruits and vegetables
a day.122 In an affluent city like London, almost 1 in 10
children reports going to bed hungry.123
The UK faces the dual challenge of confronting ‘food
swamps’ in poor areas, by restricting the promotion
of unhealthy food, while ensuring that retailers in poor
areas offer affordable healthy food.
© iStock.com/Bea Kiss
0 1 | C H I L D M A L N U T R I T I O N T O D AY » S P O T L I G H T » 5 3
The UK Government has pledged to halve childhood obesity
and reduce the obesity gap between children from the
richest and poorest areas by 2030.124 The UK introduced
a sugary drinks levy and the world’s first sugar reduction
programme aimed at a 20 per cent reduction in the most popular
products consumed by children.125 The UK is also consult-
ing on new legislation to ban unhealthy foods at checkout
areas, store entrances and the end of aisles, as well as price
promotions encouraging over-consumption of these prod-
ucts, such as ‘buy one, get one free’, multi-buy offers or
unlimited refills.126
Local authorities have been encouraged to use their planning
powers to limit the opening of additional fast-food outlets
close to schools, while the Mayor of London has banned
advertising for unhealthy foods on the Transport for London
network.127
Recognizing that infancy and early childhood are critical times
for establishing food preferences and dietary patterns, the
UK has recently called for action to reduce sugar in commer-
cial baby foods and end misleading labelling practices. Public
Health England found that some sweet snacks marketed as
suitable for babies and toddlers contain as much sugar as
confectionery.128
In parallel, the UK Government set up the Healthy Start
Scheme to provide fruit and vegetable vouchers to low-in-
come families with young children, which has helped in-
crease these families’ spending on fresh fruit and vegetables
by 15 per cent.129
Even though much remains to be done to tackle childhood
obesity, the UK is paving the way to ensure that all children
grow up in a healthy food environment.¢
54 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Why are so many
children eating too
little of what they
need, while an
increasing number
are consuming too
much of what they
don’t need?
The role of food systems
The trends in children’s nutrition are
clear: on the one hand, there have been
some declines in undernutrition, notably
in stunting, albeit at far too slow a rate
to meet globally agreed targets. There
is also evidence of some reductions in
hidden hunger, but again at far too slow
a rate. On the other hand, the proportion
of children who are overweight is
rising rapidly, even in countries that
still struggle with undernutrition.
What explains these trends? In part,
they reflect a world where children are
increasingly able to satisfy their energy
needs but not their nutritional needs.
As part of the global nutrition transition
described by Barry Popkin,75 more
and more people are moving towards
modern diets high in saturated fats,
trans-fats, sugar and salt. This transition
is linked to a rising prevalence of diet-
related NCDs. Low-quality diets are now
believed to be the single biggest risk
factor for the global burden of disease.76
The result is that more children are
surviving, but far too few are thriving –
failing to develop to their full physical
and mental potential. In such a world,
we need increasingly to focus on
the quality of children’s diets and
ask this question: Why are so many
children eating too little of what
they need, while an increasing
number of children are consuming
too much of what they don’t need?
To answer this question requires
getting to grips with food systems
– everything that happens to bring
food ‘from farm to mouth’. As work
by numerous international experts –
including the FAO, IFAD, the Global
Panel on Agriculture and Food Systems
for Nutrition, and the High Level
Panel of Experts on Food Security
and Nutrition – has demonstrated, the
processes and activities that shape
what we eat today are becoming
increasingly complex. 77, 78, 79
To better explain how these processes
affect children, UNICEF worked with
international experts to develop the
Innocenti Framework on Food Systems
for Children and Adolescents (see
below). 80 This framework puts children’s
diets at the heart of food-system analysis
for two reasons: first, because children’s
nutritional requirements are unique and
critical; and second, because there are
no ‘magic bullet’ solutions to improving
children’s nutrition over the long term,
other than having food systems that
deliver nutritious, safe, affordable and
sustainable diets for all children. Action
is needed at different points in the food
system – with synergistic actions in the
health, water and sanitation, education,
and social protection systems – (see
Chapter 4) to both increase the supply
of, and demand for, nutritious foods.
The Innocenti Framework has
three main components – drivers,
determinants and interactions.
Drivers
The ways in which societies supply and
distribute food to children, the range
of choices available to caregivers and
consumers and the decisions that they
take can all be affected by drivers that,
at first glance, may appear distant from
food systems. In recent decades, for
example, factors such as rising incomes,
technological innovation, marketing
and globalization have all helped to
transform food systems and the diets
they deliver to children and adolescents.

Determinants describe the processes, conditions
and actors most directly involved
The core of the Innocenti Framework in the production and consumption
consists of four determinants that of food for and by children.
BOX 1.2 | How can agriculture better support nutrition?
Agriculture is the foundation of all food systems
and key to providing children with nutritious, safe,
affordable and sustainable diets. However, the interaction
between agriculture and children’s nutrition is far from
straightforward.
At one level, this reflects the reality that child nutrition
goals may conflict with economic and political goals.82 For
example, while investment in agriculture has improved
productivity, food diversity has declined: just three crops
(rice, wheat and maize) now account for nearly two
thirds of the world’s calorie intake.83 At another level,
this reflects the wide variety of food production systems
globally – urban and rural, small and large, traditional
and modern – all of which may affect nutrition outcomes
in different ways.
Modern and industrialized food systems offer production
efficiency gains and year-round access to low-cost foods,
but they are increasingly oriented toward producing
animal feed, industrial inputs for processed foods, and
biofuels rather than food for primary consumption. This
has both dietary and environmental impacts, including
loss of biodiversity, soil and water contamination, and
the production of greenhouse gases.84
Smallholder opportunities
The dynamics are different in traditional food systems,
where food safety and food loss are greater concerns.85
Around four out of five of the world’s rural poor make
some or all of their living from agriculture,86 many
as smallholders – a loosely defined term that can be
thought of as referring to small family-run holdings
that produce a subsistence crop and one or two cash
0 1 | C H I L D M A L N U T R I T I O N T O D AY » 55
The processes and
activities that shape
what children eat
today are becoming
increasingly complex
crops. The decisions taken by – and options available to
– smallholders can have major effects on the nutrition
of some of the world’s most disadvantaged children.
Smallholders face choices over whether to produce a
more nutritious and diverse array of foodstuffs for
the family’s own consumption, or whether to sell what
they produce to provide extra income. This income
can be increased further if the family processes food
before selling it; however, they may only be able to
do this if they can access functioning markets and
transportation.87
Another way in which smallholder agriculture can affect
children’s nutrition is if it leads to the empowerment
of women, who play a major role in farm work, food
processing and child feeding. Women’s participation
in agriculture has the potential to help shift control
of household resources to them, which then become
more likely to be directed toward child feeding and
care.88 However, programmes aimed at strengthening
the role of women can unintentionally harm children’s
nutrition if they compete with child feeding and care
– including breastfeeding – or impair women’s own
health and nutrition.89 This underlines the need for
initiatives for women in agriculture to be accompanied
by other interventions, such as in nutrition counselling
and support, behaviour change communication, and
providing access to water, sanitation and health services.
While more work is needed to demonstrate how
agriculture can best improve children’s nutrition, the
potential is clear, as is the certainty that fundamental
change in children’s nutrition cannot happen without
the support of agriculture.¢
56 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

The Innocenti Framework on

Food Systems for Children and Adolescents
The Innocenti Framework identifies some of the key points in food systems where action can be taken
to increase both the supply of, and demand for, nutritious foods for children and young people.

Drivers of Social
food systems and cultural
Personal food environments drivers
(Individuals and households)

Political
and economic
Demographic drivers
drivers

Key components
†† Accessibility of food Behaviours of caregivers, children and Diet of child/
†† Affordability of food adolescents adolescent
Food supply chains
†† Convenience of food
Caregivers Children and adolescents

Key components
†† Production of food
†† Storage and distribution Key components
†† Processing and packaging †† Socioeconomic characteristics
External food environments †† Intra-household dynamics
†† Retail and markets
(Retail and commercial markets, †† Acceptability and desirability of food
schools, informal food vendors) †† Food preparation and eating patterns

Biophysical
18% 1%
and environmental
Key components drivers
Innovation and
†† Availability of food
technological
drivers †† Price of food
†† Quality and safety of food
†† Marketing and regulation of food

The Innocenti
Framework puts
children's diets at
the heart of food-
Source: UNICEF, 201981 system analysis
 0 1 | C H I L D M A L N U T R I T I O N T O D AY » 57

Food supply chains comprise all
the actors and activities involved in
producing, processing and distributing
food (and, ultimately, to disposal or use
of waste). Agricultural production is still
the source of most of what children
eat, and offers key opportunities for
improving children’s nutrition, for example
by researching and developing more
nutritious crops. Other interventions
can include equipping smallholders and
women to grow nutritious vegetables
and to raise short-cycle livestock, such
as poultry and goats, and developing
mixed farming and cropping systems and
aquaculture for fish production. There
are also opportunities along the length
of food chains to support better nutrition
for children, such as fortifying foods with
essential micronutrients, and reducing
the use of saturated fats, trans-fats,
sugar and salt. Improved food storage Nutritional
and management can reduce food education and
safety risks and contaminants, while information are an
minimizing food loss and spoilage. important response
to influence lifelong
External food environments describe, behaviour for
firstly, all the physical places where healthier food
caregivers, children and adolescents go to choices, habits and
purchase or consume food. What foods overall nutrition
and food items are on offer in stores
and markets do much to determine the
accessibility, affordability and convenience
of food choices. For families living
in ‘food deserts’, for example, fresh
produce may simply not be available (see
Chapter 3). Also important in external
food environments are marketing and
advertising, which help to shape tastes
and influence purchasing decisions.90
Key interventions in external food
environments to improve children’s

Traditional staples are the foundation of Uruma and her family’s diet in Tanzania. She often struggles to find
enough to feed her family. “The children sometimes go to school in the morning without eating anything,” she says.
When her husband earns a little extra, “I may return with meat, so the children can enjoy eating meat.”
Produced/photographed by MAKMENDE
58 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

nutrition can include enforcing standards
on food fortification. In addition, a
mix of taxes and tax incentives can
lower demand for unhealthy foods and
encourage the supply of healthy foods.
Other actions can include regulation of
packaging and labelling and of marketing,
especially of foods targeted at children
and young people (see Chapter 4).
Personal food environments represent
the factors that help determine and, in
many cases, limit the dietary choices
of families and children. These include
families and children's access to shops
and markets and their purchasing power,
which will determine the affordability
and convenience of food (see Chapter
3). As well as a lack of income, lack of
time is a significant burden. Rural women
in particular must often balance unpaid
farm work with their role as primary
caregivers.91 Important responses can
include providing families with cash
transfers that, with appropriate nutrition
counselling and support, can offer
extra resources and desire to purchase
nutritious food for children.92 There is
also scope to address time poverty by
reducing the burden of women’s farm and
domestic work. For example, improving
access to household water sources can
cut the amount of time women spend
collecting water, and likewise, better tools
can speed up planting and weeding, while
day-care centres can support childcare.93

In Mexico, Gabriela tries to feed her family healthy foods, such as salad at lunchtime, but six-year-old Ikal has
other ideas. “Mom, can I have a candy?” he begs. Gabriela finds it overwhelming: “They’re just children,” she says,
“Everything has pretty pictures on it. Everything … has sugar. They’re still kids, so they want sweets all the time.”
Produced/photographed by MAKMENDE
 0 1 | C H I L D M A L N U T R I T I O N T O D AY » 59

Like many young people, Indonesian teenager Rafsi is taking more of his own decisions about what to eat, especially
when he hangs out with friends in the mall. Rafsi is trying to lose weight: “I go to the gym,” he says, “I hope I will lose
more because still right now I’m overweight.” But it’s not easy: “It’s difficult to eat healthy when our friends are
eating more delicious foods than healthy foods.”
Produced/photographed by MAKMENDE

The behaviours of caregivers, Interactions

children and adolescents – or how
families, children and young people
procure and prepare food and how
children are fed and supervised – is
influenced by many factors. These include
eating patterns, nutritional knowledge,
taste preferences, appetite and levels
of physical activity. Also important are
socio-economic factors, such as food and
dietary taboos, and the tendency in some
cultures to prioritize boys and men over
girls and women at mealtimes. Nutrition
information, education and counselling
are an important response to influence
lifelong behaviour for healthier food
choices, habits and overall nutrition.
None of these four determinants stands
completely alone. As the arrows in the
framework indicate, they interact
with each other, shaping and
reinforcing each other in ways that
can both help and harm children’s
nutrition. For example, while the
food offered in local markets helps
shape the diets of children and
families, it is in turn influenced by
demand from children and families.
These interactions show the
importance of ensuring that policies
to improve the supply of nutritious
foods must also strengthen demand.
60 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Malnutrition What are the economic
can harm a impacts of children’s
child’s economic
malnutrition?
prospects and, as
a consequence,
broader socio- The coming decades will see a dramatic
economic shift in the contours of the world’s
development in population – one that will see Africa
numerous ways become the centre of global population
growth. By 2050, the population of Africa
is forecast to have doubled since 2017,
reaching a total of 2.5 billion people. In
short, the future of humanity will be
increasingly African. As populations age
in much of the rest of the world, Africa
over the coming decades will still be a
young continent; in 2050, it will be the
place where just over two out of five
of the world’s children are born.94
The emergence of a large and young
labour force in such a short period
of time will provide Africa – as well
as India and some other countries in
South and Southeast Asia – with the
chance to harness their demographic
dividend. But that potential will be
realized only with improvements in
human capital – people’s education,
training, skills and health.95 Malnutrition
stands in the way of that happening.
The impact on children
There are numerous ways in which
malnutrition can harm a child’s economic
prospects and, as a consequence,
broader socio-economic development.
Stunting in the first 1,000 days is
associated with poorer cognitive
development and lower educational
outcomes.96 Evidence from a number of
countries indicates that malnourished
children spend less time in school,
typically because of poorer brain
development and school readiness,
illness or because they start school
later in life and are more likely to have
to repeat grades. In sub-Saharan Africa,
for example, research has shown that
children lost up to 2.5 years of schooling
if there was a famine while they were
in utero and during their childhood.97
By contrast, there are also numerous
examples of how better nutrition is
associated with improvements in
children’s school performance. In the
1940s, for example, the United States
Government required bread to be
fortified to help overcome widespread
iron deficiency. Subsequent analysis
showed improved rates of school
enrolment.98 Similarly, Tanzanian
children who received intensive iodine
supplementation in the late 1980s
and 1990s spent up to around an
extra half-year in school compared
with children who had not been
treated.99 Studies on supplementation
programmes in Guatemala100 and in
China101 also suggest that children
improved their performance in areas
such as mathematics and reading.
Perhaps the most direct way of
demonstrating malnutrition’s effects on
an individual’s economic prospects is
to look at its association with reduced
earnings – in effect, the impact of
malnutrition on productivity. Available
research indicated that the average
lifetime lost earnings associated with
stunting is US$1,400 per child, ranging
from under US$300 in Tajikistan to
over US$30,000 in wealthier countries
such as the Bahamas, United Arab
Emirates, Kuwait and Qatar.102 Studies
have also suggested that stunting is
linked to lower earnings: according to
one, an increase of one centimetre in
height in adulthood was associated
with a 4 per cent increase in wages
for men and 6 per cent for women.103

An additional, and easily overlooked,
way in which malnutrition can affect
children’s social and economic prospects
is by fuelling conflict. There is growing
evidence that poor economic and
health status, including malnutrition, is
associated with higher rates of armed
conflict. According to one analysis
in 2008, lowering the prevalence of
under-5 malnutrition by 5 percentage
points was associated with a decrease
in the likelihood of conflict of up to
3.5 percentage points.104 The reasons
for this are not fully clear, but as John
Boyd Orr, first Director-General of the
FAO, once said, “We cannot build
peace on empty stomachs.”105
All these impacts on the individual
serve to undermine the ability of
countries to develop their human capital,
defined as the “aggregate levels of
education, training, skills, and health in
a population”.106 This loss is significant.
According to the African Union’s Cost of
Hunger in Africa study, child malnutrition
costs African economies between 1.9
per cent and 16.5 per cent of GDP every
year.107 More recent studies indicate
that malnutrition continues to exert a
heavy burden on Africa’s economies.108
Much less work has been done on
estimating the cost of childhood obesity,
especially in low- and middle-income
countries. Overweight can have an
impact on the broader economy by
making individuals less productive
– through lower levels of physical
activity and higher rates of NCDs – and
by raising the cost of healthcare to
treat conditions such as hypertension,
diabetes and stroke. According to
estimates prepared for WHO, if current
trends continue, economic losses in
low- and middle-income countries from
heart disease, cancer, diabetes and
0 1 | C H I L D M A L N U T R I T I O N T O D AY » 61
chronic respiratory disease will reach
more than US$7 trillion over the period
2011–2025, equivalent to about 4 per
cent of these countries’ annual output.
Investing in nutrition
Nutrition must be seen as a cornerstone
investment if the world is to achieve
the Sustainable Development Goals by
2030. According to estimates by the
World Bank and others, it would cost
just an additional US$8.50 per child per
year to meet global targets for under-5
child stunting.109 That’s equivalent to
just US$5 billion a year. Two numbers
help put that figure in perspective:
it’s a little less than the combined
annual spend on advertising of around
US$7.2 billion a year by three of the
world’s largest food and restaurant
multinationals in the early 2010s.110 It’s
equivalent to just under 1 per cent of
the US$620 billion that high-income and
emerging economies spend each year
on agriculture support111 (which includes
direct payments to farmers as well as
tariff barriers and export subsidies).
Such investments have an impressive
rate of return. Every dollar invested in
reducing stunting generates estimated
economic returns equivalent to about
US$18 in high-burden countries.112 Even
without these returns, investment in
children’s nutrition must be at the heart
of any equity agenda. “Everyone puts all
their eggs in the equality of opportunity
basket,” the former President of The
World Bank, Jim Yong Kim, has said,
“But we’re essentially lying when 25% Every dollar invested
of children in the world are stunted. in reducing stunting
Inequality is baked into the brains of 25% generates estimated
of all children before the age of five. So economic returns
the only way that we can realistically equivalent to about
say there is equality of opportunity is if US$18 in high-burden
we bring stunting down to zero.”113 ¢ countries
62 U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Dr. Sania Nishtar
Special Assistant
to the Prime
Minister on
Poverty Alleviation
and Social
Protection,
Pakistan
Dr Sania Nishtar is Special
Assistant to the Prime
Minister of Pakistan on
Poverty Alleviation and
Social Protection and Federal
Minister in the Government
of Pakistan. She is also
Chair of the Benazir Income
Support Programme, and
Co-chair of the WHO High
Level Commission on NCDs.
Dr Nishtar founded the non-
profit, non-governmental
thinktank Heartfile. In
2017, she was Pakistan’s
candidate for WHO Director
General and was among the
three shortlisted finalists.
PERSPECTIVE
Why is addressing children’s nutrition important
for a country’s broader economic development?
After years of brutal conflict, Yemen has
become one of the world’s worst human-
itarian crises and is descending into fam-
ine. Even if the conflict ends tomorrow,
the consequences of this crisis will be
long-lasting, not least because of the im-
pact of malnutrition on brain development,
which in turn shapes the cognitive abilities
of future workforces. Today’s food insecu-
rity is starving Yemen of its future talent.
Unfortunately, malnutrition is not isolated
to extreme hunger in warzones. Children
around the world contend with multiple
forms of malnutrition that go beyond under-
nutrition.
Many countries are grappling with the dou-
ble burden of malnutrition. Undernutrition
in young children and overweight later in
life lead to higher risk of costly diseases,
such as hypertension and diabetes. Both
sides of the same coin of malnutrition can
be on painful display within one country
– quite feasibly within the same homes,
classrooms and playgrounds.
Major diabetes epidemics in China, Cambo-
dia and Ukraine have been linked to famines
and starvation 40–50 years earlier. Severe
food shortages in the Second World War
could be an explanation for the current high
rate of diabetes in Nauru, Singapore and
Malaysia. This raises the possibility of future
‘hotspots’ of diabetes in regions that have
droughts and famine or internal and regional
fighting (e.g., the Horn of Africa and Yemen),
once socio-economic conditions improve.
Malnutrition does not just lead to deaths and
disease. It also undermines the human right
to a healthy life, and negatively affects eco-
nomic development by escalating healthcare
costs and incurring productivity losses.
In the case of undernutrition, productivity
losses are due to decreased physical and
intellectual capacity, whereas in the case of
obesity, lost workdays, lower productivity
at work, mortality and permanent disability
come into play.
The impact of these costs on a country’s
gross domestic product (GDP) can be
massive. In Asia, the annual GDP losses
from low weight, poor childhood growth
and micronutrient deficiencies average 11
per cent. The global economic impact of
obesity is estimated to be US$2 trillion or
2.8 per cent of global GDP – roughly the
same economic cost as smoking or armed
conflict. Cumulatively, the estimated impact
on the global economy of different forms
of malnutrition could be as high as US$3.5
trillion a year, or US$500 for each individual.
Perhaps the most compelling association
of nutrition with a country’s economic
development is seen in human capital. In
2018, the World Bank launched a Human
Capital Index, emphasizing that this digital
age requires countries to urgently invest in
their people if they hope to compete in the
economy of the future.
The Human Capital Index is a composite
measure, factoring in child survival, years of

schooling and stunting. It has enabled the insight
that malnutrition is therefore directly responsible
for the loss of human capital.
Individuals who have had stunted growth may
lose schooling and experience delayed entry into
the labour force, meaning that 43 per cent of
children aged under 5 in low- and middle-income
countries are at elevated risk of poverty because
of stunting.
Investing in child nutrition would produce a long-
term impact on development. The Copenhagen
Consensus has indicated that for every dollar
spent on nutrition in the first 1,000 days of a
child’s life, the benefit could be an average of
US$45.
An average annual investment of US$7 billion
over the next 10 years would be sufficient
to achieve the global nutrition targets to reduce
child wasting and stunting and maternal anaemia
and to improve breastfeeding rates. With this
investment, 3.7 million children’s lives could be
saved by 2025, with at least 65 million fewer
stunted children, 105 million more children exclu-
sively breastfed and 265 million fewer women
suffering from anaemia compared to 2015. With-
out this investment, development opportunities
will be missed.
0 1 | C H I L D M A L N U T R I T I O N T O D AY » P E R S P E C T I V E » 6 3
© UNICEF/UN0281635/Dejongh
Costly as malnutrition is, the solutions do not need
to be. The Lancet estimates that over 820,000
children’s lives could be saved through measures
such as breastfeeding babies exclusively immediately
after birth, and continuing to feature breastmilk as
part of their diet up to 2 years of age and beyond.
However, the usefulness of free measures should
not be used to understate how effective cash can
be in the hands of those at the sharp end of mal-
nutrition. Following the Pakistan Government’s
new prioritization of nutrition, I have been invited
to lead the Benazir Income Support Programme
(BISP), which is a national cash transfer system.
The US$1.15 billion programme currently gets
money into the hands of over 5.6 million poor and
marginalized families. Independent evaluation has
shown that the programme empowers women in
particular, changing how they are viewed in their
communities. I look forward to integrating a new
nutrition-centred initiative within its framework in
order to address malnutrition further.
There is increasing awareness and evidence that
investments to reduce malnutrition do pay off and
are much needed. For the sake of our health and
economies, both now and in the future, coun-
tries need to take on the many-headed hydra
that is malnutrition.¢
64 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

02 
FEEDING
FEEDING
  AACHILD
CHILD
FORLIFE
FOR LIFE
 02 | FEEDING A CHILD FOR LIFE » 65

From the womb to adolescence, children †† Malnutrition during

pregnancy and early
at every stage of life have unique nutritional childhood can adversely
affect brain development.

needs, eating behaviours and dietary

influences, and are harmed in different
†† Generally, school-age
ways by malnutrition. Early childhood children around the
world are eating too little
nutrient-rich foods and too
is a time of rapid growth and nutritional many unhealthy snacks.

vulnerability. School-age children are

exposed to broader influences that affect
†† Obesity in adolescence
their diets and food choices. Adolescence can have lifelong
negative effects on the
presents a window of opportunity for brain, contributing to
early onset of cognitive
establishing healthy, lifelong nutrition. dysfunction during ageing.

A family in Kang Maes District, Cambodia sits outside their home as the younger children eat their
meal and the eldest child helps prepare ingredients. © UNICEF/UN074041/Pirozzi
 66 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

Food and nutrition across childhood

At all ages, children are not eating diets with enough nutrients or diversity, and they are eating too much sugar, salt and
fat. The risks at each age can lead to one or more forms of malnutrition: stunting, wasting, hidden hunger or overweight
and obesity. These conditions can affect school performance and lifelong economic opportunities, and present health
risks into adulthood.

0–5 months 6 months–2 years 3–4 years

GROWTH &
APPETITE

As growth rates increase and decrease,

so does appetite in equal measure

BREASTFEEDING FIRST FOODS

DIETS

0–2 years 6 months–2 years

INFLUENCES

EATING AT HOME WITH PARENTS, SIBLINGS AND CAREGIVERS

Less autonomy

• Lack of exclusive/continued • Inadequate diets:

breastfeeding excess sugar, salt and
• Lack of dietary diversity
RISKS

• Marketing of breastmilk fats, lacking vitamins

• Low feeding frequency and minerals
substitutes
• Eating ultra-processed foods • Marketing of unhealthy,
• Drinking sugar-sweetened ultra-processed foods
beverages • Lack of physical
activity

Source: Elizabeth Fox, ‘Characteristics of children's dietary needs, intake patterns, and determinants that explain their nutrition behaviors’ (unpublished).
 02 | FEEDING A CHILD FOR LIFE » 67

At every stage of childhood,

children have unique
nutritional needs, risks
and eating behaviours

5–9 years 10–14 years 15–19 years

CHILDHOOD DIETS
3–19 years

EATING AT SCHOOL
EATING OUT WITH FRIENDS

More autonomy

• Snacking
• Skipping or missing meals
• Negative self-image D
• Peer influence on food choice
68 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Lack of proper Introduction
nutrition during
the early years Across every stage of childhood – from
can have lifelong the womb until adulthood – a child’s
consequences nutritional needs, and the behaviours and
influences on diet evolve and change.
An infant undergoes vast physiological
changes week by week. As children
start school, eating patterns and diet can
change drastically. Later, adolescents
have opportunities to establish lifelong
healthy eating habits, yet are vulnerable
to the long-term effects of overweight
and obesity. Proper maternal and child
nutrition in the early stages of life
lead to lower health risks across the
life course and the prevention of non-
communicable diseases (NCDs).1 An
understanding of these differences
across childhood is important for the
design of policies and programmes that
support child nutrition effectively.
As a child grows, the main influencers on
diet shift gradually from mainly parents
and other caregivers in the early years to
the staff of day-care centres and schools
and, finally, to peers and friends in the
school-age years and adolescence. Food
marketing and broader social forces
affect what parents and caregivers feed
their children, and act more directly on
children’s food choices as they grow older.
Early years: Vulnerability and
opportunity (the first five
years of life)
Early childhood is a time of rapid physical
growth and brain development. Lack
of proper nutrition and exposure to
illness and infection during these early
years can have lifelong consequences
on educational attainment and health
and economic outcomes, especially
for children from the poorest and
most marginalized communities.
The first 1,000 days – from the point of
conception to around the child’s second
birthday – are especially crucial. Poor
maternal nutrition before conception
and while the child is in the womb, the
absence of exclusive breastfeeding in
the first six months, and the inability
of caregivers to provide a diverse and
nutritious range of ‘first foods‘ can lead
to stunting, wasting and micronutrient
deficiencies. For children and their
communities, the consequences can
be profound and lifelong.
Impact of maternal malnutrition and
malnutrition in early childhood
Good nutrition starts even before birth.
Poor maternal nutrition affects the child
while in the womb and during childbirth.
Maternal malnutrition, in the form of
underweight and anaemia, increases the
risk of pre-term birth and low birthweight,
which in turn increase the risk of
neonatal death, stunting and wasting.
In addition, maternal overweight is a
common complication of pregnancy:2 it
increases the risk of gestational diabetes
and pre-eclampsia, a potentially life-
threatening complication, and can lead
to difficulties in labour and higher rates
of post-partum haemorrhage. There
are risks for the child too, including
pre-term birth,3 low birthweight, not
initiating breastfeeding, and an increased
risk of overweight later in life.4
The developmental demands of the foetus
increase micronutrient requirements;
many pregnant women experience hidden
hunger or micronutrient deficiencies
(see Chapter 1). Iron deficiency can lead
 02 | FEEDING A CHILD FOR LIFE » 69

How breastfeeding helps the mother and child

Economic benefits

Higher adult earnings

Lower healthcare costs
Gains due to increased productivity

Benefits for child

Lowers neonatal and infant mortality Benefits for mother

Protects against diarrhoea and respiratory infections
Protects against middle-ear infection Helps prevent post-partum haemorrhage
Reduces incidence of leukemia Improves birth spacing
Reduces sudden infant deaths and life-threatening Decreases risk of breast and ovarian
necrotizing enterocolitis (intestinal disease) cancer
Lowers likelihood of overweight and obesity
Improves school performance and intelligence test
scores

Source: Greg Sclama, ’What is the impact of malnutrition in all its forms on the
development of the child?‘ (2018).

to anaemia. In fact, iron deficiency is

the most frequent cause of nutritional
a child during this period can establish
lifetime brain function. A well-nourished
Breastmilk is
anaemia.5 Folate prevents neural-tube child can interact with the environment not just food –
defects such as spina bifida in the and caregivers in a way that supports
foetus.6 Calcium reduces the risk of pre- further healthy brain development.10 it’s a powerful
eclampsia and pre-term birth.7 Vitamin
A supports immune function and foetal The power of breastfeeding
medicine
development, especially during the third tailored to the
trimester.8 Finally, a lack of zinc in mothers The wide-ranging benefits of
is associated with low birthweight, poor breastfeeding – for a child’s healthy infant’s needs
foetal neural developments, pre-term immune system, brain development
delivery and increased neonatal mortality.9 and microbiome – are well documented
and reflected in a global consensus
While the effects of nutrition on the within the nutrition community. UNICEF
brain vary across childhood, brain and WHO recommend exclusive
development is fastest during the early breastfeeding for the first six months
years. Malnutrition during pregnancy and continued breastfeeding up to two
and early childhood can adversely affect years old or beyond. As the World Bank’s
brain development, affecting cognition, Keith Hansen memorably wrote in The
school readiness, behaviour and Lancet in 2016, “If breastfeeding did not
productivity into the school-age years already exist, someone who invented
and beyond. Providing essential energy, it today would deserve a dual Nobel
protein, fatty acids and micronutrients to Prize in medicine and economics.”11
70 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

Only 2 out of 5 Breastfeeding has profound benefits for respiratory-related disease. Other benefits
newborns begin the child, especially in the first hour of include improved school performance15
breastfeeding in the life. Colostrum, the first milk produced and higher adult earnings, as well as
first hour of life by a mother, protects an infant’s improved physical well-being. Growing
immature immune system against evidence also points to breastfeeding
infection and inflammation.12 Babies reducing overweight, obesity and chronic
who begin breastfeeding in their first diseases such as diabetes later in life.16
hour have a much lower risk of dying,
even compared with babies who begin The dividends from breastfeeding are
breastfeeding later on in their first day.13 particularly high in lower-income countries,
where families are often unable to access
Breastmilk is not just food – it’s a clean water and healthcare. Even in
powerful medicine tailored to the high-income countries, breastfeeding
infant’s needs that can significantly is still important for health and healthy
reduce the risk of death.14 Universal growth and development. For example, it
breastfeeding could save the lives reduces sudden infant deaths and life-
of 820,000 children under 5 annually threatening necrotizing enterocolitis, a
worldwide. Breastfed children also potentially fatal inflammation of the gut
have much lower rates of diarrhoea and that affects mostly premature infants.

FIGURE 2.1 | Percentage of infants aged 0–5 months fed infant formula, by UNICEF region, 2018

Middle East and

North Africa

The rise in use 28%

of breastmilk
substitutes East Asia and Eastern

is an area
Pacific* and
Southern
Africa Latin America and
28% 4%
Caribbean*

of growing West &

37%
concern Central
Africa
6%
South
Asia
Global
11% 6%

Notes: Between 2008 and 2013, sales of (typically cow’s) milk-based formula grew by 41 per cent globally and by 72 per cent in upper middle-income countries such as Brazil, China, Peru and
Turkey. Analysis based on a subset of 73 countries with available data between 2013–2018, covering 61 percent of the global population. Regional estimates are presented only where available
data represents at least 50 percent of the region's population.
*To meet adequate population coverage, East Asia and Pacific does not include China and Latin America and Caribbean does not include Brazil. Data not available for Europe and Central Asia and North America.
Source: UNICEF global databases, 2019.
 02 | FEEDING A CHILD FOR LIFE » 71

FIGURE 2.2 | Trends in percentage of infants aged 0–5 months exclusively breastfed, by UNICEF region, around 2005 and around 2018

56 54
2005
2018 Many regions
45
42
have made
39 38
35 34 33 31
35 gains in
28 29
23
20
25 exclusive
breastfeeding
Eastern South Latin America West and Eastern Middle East Global
and Southern Asia and Central Europe East and Asia and
Africa Caribbean* Africa and Central North Pacific
Asia* Africa

Notes: Analysis based on a subset of 80 countries with comparable trend data covering 74 per cent of the global population for around 2005 (2003–2008) and for around 2018 (2013–2018).
Regional estimates are presented only where available data represents at least 50 percent of the region's population.
*To meet adequate population coverage, Latin America and Caribbean does not include Brazil and Eastern Europe and Central Asia does not include Russian Federation.
Source: UNICEF global databases, 2019.

Mothers benefit from breastfeeding too.
It helps prevent heavy bleeding after
birth and accelerates the contraction
of the uterus. In addition, because
lactating mothers are less likely to ovulate
while breastfeeding, it improves birth
spacing. There is also robust evidence
of protection against breast and ovarian
cancer,17 some evidence of a reduced
risk of type 2 diabetes, and a reduction of
hypertension and lower cardiovascular risk
among mothers who breastfeed.18
Why are so many children not
breastfed?
Despite these benefits, far too many
babies are not breastfeeding optimally.
Only just over two out of five (44 per
cent) of newborns begin breastfeeding in
the first hour of life and around the same
proportion (42 per cent) of children under
six months are exclusively breastfed. Why?
The answer is complex, but it includes
factors such as the promotion of breastmilk
substitutes, social and cultural taboos
against breastfeeding, the struggle many
women face to balance work with childcare,
and lack of support for breastfeeding.
Breastmilk substitutes
In the first three days of life, 43 per
cent of newborns worldwide are given
liquids or foods other than breastmilk,
most commonly sugar water, honey,
tea, animal milk, infant formula or plain
water.19 In West and Central Africa,
water is the most common liquid given
to infants in the first three days after
birth, potentially exposing them to
pathogens and other life-threatening
substances. Elsewhere, many infants
in Latin America and the Caribbean do
not receive breastmilk at all and receive
breastmilk substitutes – in Mexico, 48
72 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
SPOTLIGHT
A day is (almost) never enough: The daily life of a breastfeeding working mother in rural Laos
Xaiathon lives in Houychengkao Village in rural Laos. At 33
years old, she has four sons ranging in age from 2 months
to 15 years. Together with her husband, she farms a small
lot and maintains a home with their children.
“My day starts very early, because of the long walk to the
farm,” she says. Because of this, her breastfeeding prac-
tice is not as regular as her doctor has advised. In addition
to farm work and preparing meals for the boys, Xaiathon
gathers firewood, feeds the hog and cattle, does the laun-
dry, cleans the house, and helps out at a neighbour’s farm
to augment their barely-enough harvest.
She’s usually only able to breastfeed Kaka (her youngest
son) when she’s at home in the morning before going to
the farm (which is an hour’s walk from their home), and
again in the evening when she’s back. “It is a challenge
to keep up because of the farm work. Sometimes when
it rains, I can’t go back home to breastfeed them, so in
the rainy season I make sure there’s rice porridge left at
Before heading out to the farm, Xaiathon gathers and cuts the fire wood, and clears their backyard garden of bushes. “I also consider this a bit of warm-up, before the
real hard work at the farm awaits,” she says with a smile. © UNICEF/Laos/2018
home. A few times I’ve had my fellow mothers in the
neighbourhood breastfeed my boys,” she says.
To make up for the lack of breastmilk during the day, she
chews pieces of meat and mixes them with the rice por-
ridge that she has prepared for Kaka in the morning. Her
heavy workload means Xaiathon is also unable to follow
through with her visits to the health centre in town. “I
would rather just spend the time at the farm instead,” she
says, adding that their meagre harvest is the only source
of income for their family of six.
As the sun sets and her husband approaches their
home, the boys run to greet him, eager to see what
fruits he has got for them along the way. For Xaiathon,
the day is only halfway done: she still has to prepare
dinner, do the dishes and feed her little son. She will
try to get some rest as soon as the boys are back from
evening playtime with their neighbours, mindful of an-
other early start the next day.¢

per cent of infants 0–5 months and 33 per
cent of children 6–11 months consume
infant formula, while only 35 per cent of
children under 2 consume breastmilk.20
The rise in the promotion, sales and use
of breastmilk substitutes, including follow-
on formulas and toddler milks, is an area
of growing concern. These products are
often marketed with misleading claims
that they improve young children’s IQ
and immune systems, or are necessary
for healthy growth. Between 2008 and
2013, sales of (typically cow’s) milk-based
formula grew by 41 per cent globally and
by 72 per cent in upper middle-income
countries such as Brazil, China, Peru
and Turkey.21
The fastest growing category of
formula milk is toddler milks, marketed
for children aged between 13 and
36 months. Global sales grew by 53
per cent between 2008 and 2013.22
Unnecessary for healthy growth, these
drinks may also increase the child’s
preference for sweet tastes.23 Compared
with formulas, which contain added
sugars, breastmilk exposes children to
a broader range of tastes and flavours
from the mother’s diet, thus preparing
children for a more diverse diet as they
grow older. Most toddler milks contain a
combination of powdered milk without
its natural fats, and corn syrup and other
added sweeteners and vegetable oil.
Public health professionals have
raised concerns about the rise in
the use of toddler milks. “My view
is that these companies created a
fake feeding period that they filled
with this new product,” New York
University’s Jennifer L. Pomeranz has
said. “We’re adding in now another few
years of processed food consumption
that didn’t previously exist.”24
02 | FEEDING A CHILD FOR LIFE » 73
Social norms and healthcare
Social norms, taboos and traditional
practices significantly influence feeding
behaviours. For example, many cultures
believe babies should not consume
colostrum and should be fed another liquid,
such as sugar water, honey or animal
milk, before beginning breastfeeding.
To begin breastfeeding immediately after
childbirth, mothers need support from
health professionals. However, a 2018
UNICEF report found that the presence of
a medical doctor, nurse or midwife at the
time of delivery did not necessarily support
the early initiation of breastfeeding.25 Only
34 per cent of newborns delivered by a
skilled birth attendant began breastfeeding
within the first hour of birth in South
Asia, while the rates are only 45 per
cent in Middle East/North Africa, 47 per
cent in Latin America and Caribbean,
and 48 per cent in East Asia and Pacific.
Another emerging concern is the rise of
caesarean delivery. Research in South
Asia has found that caesarean delivery is a
significant predictor of delayed initiation of
breastfeeding.26 Across 51 countries, early
initiation rates among newborns delivered
by vaginal birth were more than twice as
high as initiation rates among newborns
delivered by caesarean section.27
Mothers living with HIV can breastfeed
without negative consequences for
their own health and the health of their
children. When these mothers take
antiretroviral medicine consistently
throughout the breastfeeding period,
the risk of transmitting HIV to their
children is extremely low. To achieve
safe breastfeeding among mothers Social norms, taboos
living with HIV, scaling up treatment and traditional
services and adherence counselling practices significantly
and support within health facilities at influence feeding
the community level are required. behaviours
 74 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

What are young children eating?

The importance of first foods

FIGURE 2.3 | Percentage of children aged 6–23 months fed food groups, by type, global, 2018*

%
Grains 78 When children start eating
Breastmilk
76 soft, semi-solid or solid
Dairy
48 foods at 6 months old,
Vitamin A rich
fruits & vegetables 47 they need nutritious and
Flesh foods 32 safe diets with a range of
Other fruits
& vegetables 27 nutrients to grow well.
Legumes 22
Eggs 22

Without enough diversity in

59% of children worldwide are not
children's diets, they may not get
being fed much-needed nutrients enough nutrients to grow well,
from animal source foods. which can take a devastating
toll on children’s bodies and
brains. UNICEF and WHO
44% of children worldwide are not recommend that children at
fed any fruits or vegetables. this age eat a minimum of
five of eight food groups.

FIGURE 2.4 | Percentage of children aged 6–23 months eating at least 5 of 8 food groups (Minimum Dietary Diversity), by UNICEF region, 2018**

Fewer than 1 in 3 children

eats foods from the minimum % 29 20 24 25 36 40 60
number of food groups Global South Asia Eastern and West and Middle East East Asia and Latin America
Southern Central Africa and North Pacific and the
Africa Africa Caribbean

FIGURE 2.5 | Percentage of children aged 6–23 months eating at least 5 of 8 food groups by wealth quintile and place of residence, global, 2018***

Only 1 in 5 children from the poorest

households and rural areas eats foods %
21 38 23 39
from the minimum number of food groups
Poorest Richest Rural Urban

* Analysis based on a subset of 72 countries with data available between 2013–2018 covering 61 per cent of the global population.
** Regional and global estimates based on the most recent data for each country between 2013–2018.
*** Analysis based on a subset of 74 countries with disaggregated data available between 2013–2018.
Source for all figures pages 60–61: UNICEF Global Databases, 2019.
 02 | FEEDING A CHILD FOR LIFE » 75

2 in 3 children aged 6–23

months are not eating
foods from the minimum
number of food groups
FIGURE 2.6 | Percentage of children aged 6–23 months fed food groups, by type, by World Bank income group, 2018

44
While the vast majority

75
of young children
22
13

consume breastmilk,
31

78
20

25
they are not eating enough
animal source foods, fruits,
EGG
S
legumes or vegetables and
61
GU
M
ES GR
AI
N 89 rely too heavily on grains.
LE S

What are young

AB S

25
S
ET RUIT

Except for breastmilk,

LE

children eating
& V ER F

based on country the percentage of young

EG
OTH

18

income level? children consuming any of

the other 7 food groups is
FLESH FO

57 83
Low-income countries systematically higher in upper-
middle-income countries
% Lower-middle-income
ODS

ILK

countries
STM

29
than in low- and lower-
EA

Upper-middle-
middle-income countries.
BR

income countries*
VI &
TA V

N
M E

31
G AR
I

ET IC 78
AB H F
LE RU
S ITS
The percentage of children
DAIRY
52
consuming non-dairy animal
47 source foods such as eggs, meat,
poultry and fish in upper-middle-
47

income countries is nearly twice

31

as high as those in low- and

48

50
80

lower-middle-income countries.

FIGURE 2.7 | Percentage of children aged 6–23 months fed food groups, by type and age, global, 2018

89 6–11 months
85
70 12–23 months
65

% 51 55 Younger children are

42 38
33 31 26 26
eating less diverse diets
19 18 15 14 compared to children 1–2
years of age.

Note for Figure 2.7: Analysis based on a subset of 72 countries with data available between 2013–2018 covering 61 percent of the global population. Income groupings are based on the FY19 World
Bank income classification. Estimates by World Bank income groups are only displayed if available data represents at least 50 percent of the population.
*To meet adequate population coverage, upper-middle-income countries do not include Brazil, China and the Russian Federation.
76 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Children aged 6–23
months can suffer
lifelong consequences
if they eat unhealthy
diets that lack diversity
and rely on foods high
in sugar and fat and low
in essential nutrients
Balancing work with childcare
Unfortunately, working mothers world-
wide face barriers to breastfeeding.
Mothers in the workforce need a
supportive environment, including
paid maternity and parental leave
and breastfeeding breaks for working
mothers. In a 2015 study involving
11,025 participants from 19 countries,
maternal employment was the most
frequently cited barrier to exclusive
breastfeeding.28 Attention paid at a
national level to supporting working
mothers in the workplace can have
significant effects. Viet Nam, for
example, extended paid maternity
leave in 2012 from four to six months –
a bold departure from other maternity
leave policies in Southeast Asia. Since
then, the government has mandated
all workplaces with a substantial
female workforce to offer childcare
facilities and lactation spaces.29
The importance of complementary
foods and why children are not
getting them
When children are around 6 months
old, breastmilk is insufficient to provide
all the energy and nutrients they need.
Their nutritional needs for growth
and development between 6 and 23
months are greater per kilogram of
bodyweight than at any other time of
life, making them especially vulnerable
to nutritional deficiencies and growth
faltering. Introducing a healthy and
diverse range of complementary
foods along with breastfeeding can
help protect against illness and death,
while also ensuring healthy growth
and development and preventing
overweight/obesity later in life. Equally,
children between 6 and 23 months can
suffer lifelong consequences if they
eat unhealthy diets that lack diversity
and rely on foods that are high in sugar
and fat and low in essential nutrients.
It is recommended that infants start
eating complementary foods at 6
months, but globally only over two
thirds of infants aged 6–8 months
are eating complementary foods.
However, far too many begin much
earlier. Nearly half of children 4–5
months of age and around 15 per
cent of infants 2–3 months of age
are already eating foods in Latin
America and Caribbean and East
Asia and Pacific regions.30 In the
United States, 21 per cent of infants
0–5 months of age consume grains,
and this is higher among African-
American infants (34 per cent).31
Starting from 6 months of age,
children benefit especially from foods
of animal origin, including meat,
fish, eggs and dairy products, which
are effective in providing them with
essential nutrients and vitamin A, iron,
zinc and calcium that are so needed
between the ages of 6 and 23 months.
Animal-source food (ASF) supports
growth and physical activity and
strengthens cognitive performance.
ASF is densely packed with a range
of essential micronutrients, well
suited to the smaller stomachs of
younger children. Stunting in early
childhood is also associated with
low consumption of ASF.32 But
ASF – especially eggs and dairy –
are expensive in low-income, rural
areas, and consumption is lower (see
Chapter 3). Globally, only two in five
children are being fed ASF. Fish –
which is relatively cheap and protein-
dense with micronutrients – is a major
part of young children’s ASF diets in
lowland areas of Africa and Asia. 33

SPOTLIGHT
Complementary feeding and behaviour change in Rwanda
Denise is a voluntary community
health worker in Akabacuzi Village,
where the legendary 1,000 hills of
Rwanda begin to slide into the dri-
er, flatter savannahs. Twenty-two
children in her village used to suffer
from undernutrition, but today, not
a single child is considered either
severely or moderately undernour-
ished. Much of this improvement
is due to Denise’s efforts to ensure
parents know what and how to feed
their youngest children and put that
knowledge into practice.
Through cooking sessions in her
home, Denise demonstrates tech-
niques to prepare nutritious food.
Recently, she showed other moth-
ers how to make beet juice, which is
rich in vitamins and minerals. Moth-
During a nutrition session, Denise, a Community Health Worker, demonstrates how to prepare beet juice for a group of women in Gatsibo District, Rwanda. © UNICEF/
UN0301144/Noorani
02 | FEEDING A CHILD FOR LIFE » SPOTLIGHT » 77
ers with children in their arms gath-
ered to share the juice, poured into
plastic cups. Previously, parents in
this community would have thought
it natural to feed young children a
diet heavy in carbohydrates such
as potatoes. Now they know this is
not enough: diverse fruits, legumes,
grains, vegetables, and sources of
protein such as eggs, fish, meat and
dairy products need to be a regular
part of their diet.
Denise and her fellow community
health workers across Rwanda are
in the vanguard of the fight against
undernutrition, for which prompting
behaviour change is a core strate-
gy. To encourage better use of local
resources, the government rolled
out the ‘1,000 Days for 1,000 Hills‘
campaign, which pushed out mes-
sages across various channels, in-
cluding community radio stations,
community health workers (who
hold monthly growth-monitoring
sessions and cooking demon-
strations), agricultural technicians
(who teach communities to create
kitchen gardens), and members of
village savings and loans groups.
Parliamentarians, religious leaders
and journalists also helped spread
campaign messages.
“At first, people did not think about
feeding children vegetables and
other healthy foods,” Denise says.
“Now we know what a balanced diet
is. As long as we keep informing and
encouraging people, no more chil-
dren here will be malnourished.Ӣ
78 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Children who are
hungry at school
struggle to pay
attention and
complete tasks and
score worse on
cognitive tests
Fruits, vegetables, legumes, nuts
and seeds are also important, not
only as good sources of vitamins,
minerals and fibre, but also because
children who learn to enjoy eating a
variety of fruits, vegetables, legumes,
nuts and seeds are likely to go on
eating them into adulthood.
Fortification
In many parts of the world, local foods
alone cannot meet young children’s
high nutrient requirements. Fortified
complementary foods or multiple
micronutrient powders can help close
these gaps. Around the world, a
range of fortified blended foods high
in proteins and micronutrients are
distributed through social protection and
supplementary feeding programmes, to
provide extra food and nutrients beyond
what is normally provided at home.34
For instance, fortification products
such as micronutrient powders enable
caregivers to add essential vitamins and
minerals to foods prepared at home
for young children, reducing forms of
hidden hunger, such as iron deficiency
and anaemia. As of 2017, programmes
providing micronutrient powders
had been implemented in at least 47
countries, reaching over 16 million
children aged 6–59 months. Infants
and young children also benefit from
eating large-scale, centrally processed
fortified foods such as iodized salt,
iron-fortified flours and vitamin-A-
fortified oil. For example, in Nairobi,
Kenya, such products meet around a
quarter of the vitamin A requirement
and half the iron requirement of children
between 6 and 23 months of age.35
Finally, biofortification – the process
of breeding staple food crops with
higher micronutrient content – can
reach vulnerable young children living
in rural areas with limited access to
diverse diets and commercially marketed
fortified foods.36 In 2017, an estimated
5 million under-5s in 14 countries in
Africa, Asia and Latin America were
consuming biofortified staple foods,
including iron-rich beans, provitamin-
A-rich maize, cassava and sweet
potato, and zinc-rich wheat and rice.
Influences on young children
As any parent knows, infants and toddlers
can be fussy eaters. Taste and food
preferences can change from week to
week and parents often offer what the
child prefers. Young children’s innate
preference for sweet foods is helping to
drive the increase in the consumption
of commercial snack foods such as
cookies, cakes and sweets and sugar-
sweetened beverages in low-income
countries.38 A 2016 study of feeding
practices among young children in
Dakar, Dar es Salaam, Kathmandu and
Phnom Penh found that the biggest
reason for mothers feeding their children
chocolates, sweets, cookies, chips or
crisps, and cakes was that “the child
likes it”, far outweighing other factors
such as affordability, convenience or
perceptions that the foods were healthy.39
The study found that, in all four cities,
young children were more likely to eat
commercially produced snack foods than
foods rich in micronutrients, such as leafy
green and orange-fleshed vegetables.
At the same time, a growing body of
evidence from high-income countries
indicates that commercial foods available
on the market do not always deserve
the ‘healthy halo‘ that they tend to have
among parents. Evidence of widespread
inappropriate promotion of commercial

SPOTLIGHT
Mothers’ clubs take a stand against malnutrition in Haiti
Jacqueline Saintil is determined to
breastfeed her 3-month-old baby
James exclusively until he is 6 months
old and then to give complementary
food in addition to breastmilk to keep
him healthy. “My 5-year-old Ervens
was not exclusively breastfed. After
three months, I gave him water and
food almost every day. He was not a
very strong baby,” she explains.
The 25-year-old mother, who sold sec-
ond-hand clothes before she gave birth
to James, grows beans in a small gar-
den that she can now harvest and sell
because of the training in nutrition she
has received. “I will make vegetable
soup, with corn and dry fish, to feed my
son when he’s six months,” she adds.
Jacqueline acquired her nutrition-
al knowledge from the local Paillant
Mothers’ Club in her town of Les
Jacqueline breastfeeds 3-month-old James. © UNICEF/Haiti/2019/Seck
02 | FEEDING A CHILD FOR LIFE » SPOTLIGHT » 79
Nippes. Thanks to a set of cards
with simple drawings, she and 29
other women were taught how to
help prevent their children catching
diseases or suffering from malnu-
trition. They learned that breastmilk
contains all the nutrients required by
babies and no other food or liquid is
necessary until the age of 6 months.
They were also shown how to make
nutrient-dense meals of purees using
local ingredients.
In mothers’ clubs, community coun-
sellors advise parents and caretakers
of children aged under 5. Each week,
mothers meet to discuss one theme on
child well-being and development.
A total of 411 women have been
trained in 20 clubs in Les Nippes. The
club is participative, interactive and
joyful. The training raises women’s
self-esteem and social status within
their communities. Women were so
proud of their achievements that they
organized a graduation ceremony at
their own expense. According to Be-
atrice Rubin of the Paillant health cen-
tre, vaccine coverage is nearly 100%
for ante- and post-natal consultations
as women from the club educate their
peers. Referrals of malnourished chil-
dren are more numerous since the
course started.
Prevention of malnutrition is key
in Haiti, which is characterized by
chronic poverty coupled with a deep
socio-economic crisis. Only 40% of
infants aged under 6 months are exclu-
sively breastfed, 11% of 6–23-month-
old children are fed following mini-
mum acceptable feeding practices,
and more than 1 in 5 children aged
under 5 years is stunted.37 ¢
80 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
As children grow foods includes labelling that encourages
into toddlerhood, early introduction, products with high
they start to choose amounts of sugar, use of artificial
their own food and flavours, inappropriate consistency
are exposed to new for developing eating behaviours, and
influences aside various nutritional and health claims.40
from their parents
and caregivers As children grow into toddlerhood,
from the ages of 2 to 4 years, they
start to choose their own food and, in
many instances, eat outside the home,
opening them to new influences aside
from their parents and caregivers. At
this age, positive models of eating
from parents, caregivers, siblings,
educators and peers become more
important and influential.41
Health professionals also play a major
role in influencing parents through
information, support, counselling and
BOX 2.1 | Responsive feeding
How a caregiver and child interact helps to shape long-
term behaviours and attitudes toward food. Responsive
feeding – the process of recognizing cues for hunger and
fullness and responding to them appropriately – helps
develop healthy eating habits beginning in infancy and
limits child underweight and obesity.
Responsive feeding is grounded in several key principles
for caregivers:
†† Attend to the child’s signals of hunger and satiety
†† Recognize and respond to the child’s feeding
needs in a prompt, emotionally supportive
and developmentally appropriate manner
†† Ensure the availability of healthy food
†† Create a safe and comfortable eating
environment with few distractions.46
Non-responsive feeding is characterized by a lack of
reciprocity between the caregiver and child. It can
reflect situations where the caregiver takes control and
care (see Chapter 3). With three quarters
of all newborns delivered with the
help of a skilled birth attendant, these
providers have a significant impact on
breastfeeding uptake and practices.
In many parts of Africa, Asia and
Latin America, mothers-in-law and
grandmothers are especially influential
on how infants and young children are
fed. However, their advice can often be
inappropriate – insisting, for example,
that colostrum is ‘dirty’ and urging
mothers to hold off feeding animal-
source foods until the child is 18 months
of age.42 Grandmothers can negatively
influence exclusive breastfeeding
either through providing advice on early
introduction of water and/or foods or
actively feeding the infant themselves
during the first six months.43
dominates the feeding situation; where the child controls
the situation; or where the caregiver ignores the child.
When caregivers dominate feeding, they can not only
override the child’s internal hunger and satiety cues, but
also interfere with the child’s development of autonomy
and independence.
According to a 2011 study, responsive feeding promotes a
child’s acceptance of food and adequate intake.47 Feeding
infants and young children in response to hunger and
satiety cues, instead of using food as a soothing strategy,
can improve sleep behaviours, which can then help
the child to be more physically active when awake and
to better self-regulate their appetite.48 A 2015 review
concluded that responsive feeding interventions are
the most promising obesity prevention measures for
children under 2 years of age. 49 Lack of responsive
feeding increases the risk of suboptimal growth and
development in environments where undernutrition
is prevalent.¢

Finally, the modern food system exerts a
significant influence on young children’s
diets. The retail sector determines the
availability of and access to breastmilk
substitutes, toddler drinks and other
foods specifically targeted at young
children, while advertising, packaging
and placement of unhealthy snacks in
supermarkets can make it difficult for
parents and children to make healthy
food choices. 44 The private sector can
contribute in positive ways when it
increases the availability, affordability
and quality of complementary foods
and supplements, distributing these
products through channels such as retail
markets, public health systems and
social marketing, and generating demand
for them among consumers (see Special
Section 'Influence of food marketing
on children's diets’, Chapter 4). 45
Middle childhood: A time of
transition (ages 5–9)
When children start going to primary
school, lifelong dietary habits continue
to be developed. A child’s family, school
and broader social forces all affect food
availability and food choices, but children
also start taking some responsibility for
their own diets. This period of transition
is important for establishing healthy
eating habits. At this age, traditional
gender roles and expectations begin
to take hold for many children in low-
and middle-income settings, with girls
often helping out in the kitchen and
caring for younger siblings, and boys
assisting in income generation.50
This period of childhood is marked
by continued, steady growth. How
much children eat during this phase
02 | FEEDING A CHILD FOR LIFE » 81
can vary widely. Appetites and
food intake can increase before
growth spurts and decrease during
slower growth periods. 51
Research also shows the potential
for children to catch up during this
age after early stunting. One study
conducted in 2010 in Peru found that
stunted children who caught up by the
age of 6 years did as well in cognitive
tests as non-stunted children.52
Nutritional needs and patterns
Far too many school-age children
around the world are eating too little
fruits and vegetables and too many
unhealthy snacks that are high in sugar,
saturated fat, sodium and salt, for
example in bread, cookies, sweets,
ice cream and sweetened beverages
that are often marketed to and popular © UNICEF/UN0283275// Frank Dejongh
among school-age children. Low
consumption of fruits and vegetables
is common – a worrying phenomenon
given that children who eat fruits and
vegetables in childhood are more likely
to continue doing so into adulthood.53
Many government departments of health
recommend five portions of fruit and
vegetables a day, but it is clear that many
children are not getting anywhere close
to these amounts. In a Brazilian study,
for example, no children aged 7–8 years
met the diet quality index for vegetables.
Children in developing countries,
especially in poorer households and
rural areas, tend to have diets made
up of a few staples such as cereals,
roots or tubers with little protein.54
Across higher and lower income
countries and across food systems,
there is a clear relationship between
diet, cognitive development and
academic achievement.55
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Overweight and
obesity in middle
childhood has
both short- and
long-term effects
Hunger is an important factor. Energy
is essential for concentration and
participation in school activities,
so children who have an empty
stomach and feel hungry at school
– from skipping breakfast or not
eating enough – struggle to pay
attention and complete tasks.
Hidden hunger also impairs school
performance; certain micronutrient
deficiencies affect learning. According
to research, iron deficiency is linked
with lower test scores. 56 Anaemia can
cause fatigue and prevent children
from paying attention in class. Eating
an adequate diet regularly (in particular
at breakfast) has been associated with
higher academic achievement, while
ultra-processed snacks and fast food
may have negative associations. 57
The effects of early malnutrition
have long-term consequences. The
impacts of nutrient deficiencies in
utero or in early childhood affect school
performance: for example, stunting
serves as a predictor of poor educational
outcomes throughout childhood. 58
Reflecting the link between diet and
school performance, some school-
feeding programmes emphasize a
diverse diet in foods that provide
a range of nutrients. For example,
Bhutan’s school-feeding programme
benefits around 45 per cent of the
country’s total student population.
Micronutrient deficiencies are a major
challenge – one in three adolescent girls
in Bhutan is anaemic, and iron deficiency
is thought to be a major cause. In 2017,
a government analysis revealed that
Bhutan’s school menus were deficient in
many micronutrients, particularly iron, B
vitamins and zinc, and did not provide
adequate dietary diversity. Recognizing
these challenges, several initiatives have
been launched. Rice, the Bhutanese
staple food, has been fortified and is
now supplied to all schools. School
menus are also reviewed to increase
diversity and nutrition in meals.
School-age nutritional risks
and concerns
Overweight (and obesity) in middle
childhood has both short- and long-
term effects. In the short term, it
can raise cardiovascular risk factors,
including type 2 diabetes, high blood
pressure, high LDL cholesterol, and
even atherosclerosis, and may also be
linked to illnesses including asthma
and low-grade systemic inflammation. 59
Through its impact on the immune and
pulmonary systems, overweight and
obesity raise the risk of infections, 60 an
impact that may be particularly severe
for hospitalized children. 61 Childhood
obesity is also linked to psychological
and social problems, including low
self-esteem, self-image and behavioural
problems. Girls appear to be at greater
risk, and the risk increases with
age. 62 In the long term, childhood
overweight and obesity increase the
risk of adult overweight five-fold 63 and
is associated with a range of metabolic
disorders in adulthood, including
diabetes, stroke, high triglycerides,
heart disease and hypertension. 64
Research has found that children
in sub-Saharan Africa, especially in
urban areas and among higher-income
households, are sitting more and
exercising less, which has implications
for their health and nutrition. 65 In this,
they are following the example of
children in high-income countries, who
now spend more than half their school
day sitting in classrooms, 66 and are

spending more time sitting watching
television or other screens at home.
Missing breakfast
Despite the clear evidence of its
benefits, school-age children around
the world commonly miss or skip
breakfast, depriving them of a meal
that particularly supports cognition,
especially among undernourished
children.67 The reasons vary, but
far too many children from poorer
backgrounds have no choice – their
families simply lack the resources or
time to feed them in the morning.
Many must rely on food provided or
acquired at school instead. According
to a WHO report, two-thirds of
countries in Africa, the Americas
and Southeast Asia provide school
meals, but meal provision is less
common in Europe and the Western
Pacific.68 For many children, therefore,
the evening meal is the main meal,
meaning they spend much of the
day feeling hungry, which interferes
with their attention in class and
affects school performance, an
effect recorded, for example, among
children in Ghana and Uganda. 69
It may seem counter-intuitive, but in
some settings, children who miss or
skip breakfast have a higher BMI than
their peers who do not. According to
research conducted in New Zealand
in 2007, this is because children who
miss or skip breakfast subsequently eat
more snacks – cookies, sweets, chips
or crisps, and sweetened carbonated
drinks that are high in calories but
low in nutrients – between meals.70
It is important to note that data on
what school-age children eat are
limited. In many studies, children
02 | FEEDING A CHILD FOR LIFE » 83
complete questionnaires at schools
without the involvement of their
parents, while younger children have
trouble self-reporting their food intake
– overestimation of food intake is
common.71 Among older students,
body image concerns can result in
less accurate reporting, and under-
reporting is likely especially among
those who are overweight or perceive
themselves to be overweight.72
The school environment
In many countries, the school
food environment promotes the
consumption of unhealthy foods
and overweight and obesity.
Ultra-processed foods and sugar-
sweetened beverages are often
sold to children in school cafeterias
or at convenience stores and
street stalls outside schools.
Changing the food environment to
provide healthier foods is not easy.
For example, Mexico has taken
action in recent years to reduce
the availability of unhealthy foods
in schools, but it continues to face
challenges. In 2010, the government
established food and beverage
guidelines for elementary schools.
However, in 2017, a study of 39
schools showed that energy-dense
foods prohibited in the guidelines
were still widely available, while
vegetables, fruits, and plain water
accounted for less than 7 per cent
of the foods and drinks available in
schools.73 In addition, advertisements
for sugar-sweetened beverages, In many countries,
pastries and sweets, many featuring the school food
gifts or special promotions, remain environment promotes
common outside schools, particularly the consumption of
state schools, and can influence food unhealthy foods and
and drink choices among children.74 overweight and obesity
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Adolescents
are especially
vulnerable to
undernutrition,
in part because
their rapid physical
growth and
development during
puberty raises their
nutritional needs
Padma, 17, chats with members of
the Adolescent Girls’ Club at Muttock
Tea Estate, Dibrughar district, Assam,
India. The club raises local awareness
about the risks of drinking salt tea.
© UNICEF/UN0324156/Boro
Adolescence: Crucial years
for lifelong nutrition
(ages 10–19)
Adolescence is a time of rapid physical
and psychosocial development and
changes that accompany puberty. Boys
have higher nutrient requirements due
to a faster growth rate and greater
gain in bone growth and muscle
mass; girls are especially vulnerable
to malnutrition, and gendered cultural
norms mean they often lack access
to nutritious food, education and
economic opportunity.75 Adolescent
girls also have higher iron requirements
than boys because of growth spurts
and the onset of menstruation.
With an estimated 1.25 billion people
aged between 10 and 19 in 2020, there
will be 250 million more adolescents
compared with just 30 years ago. Proper
nutrition for this large cohort is important
for both their current and future well-
being. Yet around the world, adolescents
routinely fail to consume diets that
would give them the foundation for long,
healthy and productive adult lives. In
rural areas, they often have limited food
options and are susceptible to seasonal
food shortages. In urban areas, they are
surrounded by fast food and nutrient-
poor snacks and drinks. In all settings,
unhealthy snacks tend to be eaten.
Hidden hunger affects tens of millions.
Adolescent dietary habits and risks
As with younger children, the diets of
adolescents in low- and middle-income
countries are generally nutritionally poor.
Among school-going adolescents, 34
per cent consume fruit and 21 per cent
vegetables less than once a day, but 42
per cent drink carbonated soft drinks at
least once a day. Just under half (46 per
cent) consume fast food at least once a
week. Half of adolescent girls in low-
income and rural settings in low- and
middle-income countries eat fewer than
three meals a day, with most missing or
skipping breakfast. Snacking is common
during school hours, and lunch is usually
eaten outside the home.76
 02 | FEEDING A CHILD FOR LIFE » 85

Adolescent dietary
habits vary across
country income groups
FIGURE 2.8 | Adolescent diets based on World Bank income group, 2008–2015

High-income countries †
34 23 62 49

Upper-middle-income countries †
28 20 57 56
%

Lower-middle-income countries †
35 19 39 44

Low-income countries †
37 30 44 48

Note: Fast-food consumption only refers to

consumption from restaurants and not street Less than Less than Sugar- Fast
foods, which are increasingly common in
Latin America, Asia, and Africa and make daily fruit daily vegetable sweetened food
up a significant portion of the urban food
supply. When fast foods were considered as
intake intake beverage intake intake
meals purchased outside the home, 93% of
adolescent girls from low- and middle-income
countries globally were found to consume Adolescents Adolescents from More adolescents More adolescents
them at least weekly.
from low- low-income from high-income from upper-
Source: Global Alliance for Improved
Nutrition (GAIN) analysis of data on income countries countries drink middle-income
adolescent diets from Global School-based
Student Health Surveys (GSHS) and Keats, countries consume carbonated soft countries eat
E.C. et al., ‘Diet and Eating Practices among
Adolescent Girls in Low- and Middle-Income consume fruit vegetables less drinks at least fast food at
Countries: A Systematic Review,’ (2018).
less frequently frequently once a day least once a week

Nutrient deficiencies, overweight/ Diet and nutrition play a key role in

obesity and pregnancy
Adolescents are especially vulnerable
to undernutrition, in part because their
rapid physical growth and development
during puberty raises their nutritional
needs. The absence of adequate nutrition
risks undermining this crucial period of
growth and development, an impact that
is compounded for the 16 million girls
between 15 and 19 years old and the 2.5
million girls under age 16 in developing
countries who give birth each year.77
brain development right into adulthood.
Undernutrition in adolescence is associated
with impaired cognitive function, school
absenteeism and psychological stress.78
As Dr Neville Golden, a member of the
American Academy of Pediatrics Committee
on Nutrition and chief of adolescent medicine
at Stanford University School of Medicine
in California, has said, “If [teens] don’t eat
right, they can become irritable, depressed
[and] develop problems such as obesity
and eating disorders – and those have a
whole host of psychological morbidities.”79
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While prevention
of stunting in the
first 1,000 days
remains a priority,
adolescence provides
a second window
of opportunity
for high return
on investment
with nutritional
interventions
There is evidence that sugar is
particularly harmful for the adolescent
brain, which is especially responsive to
rewarding behaviours. The consumption
of tasty foods high in sugar, salt and/
or fat is hard to resist, but research
in animal models indicates that
individuals who drank sugar water
during adolescence showed less
motivation and pursued rewards
as adults, behaviours that signify
depression and other mood disorders.80
Iron deficiency is a particular area of
concern. To support their rapid growth
and physical development, adolescents
need sharp increases in the intake of
certain vitamins and minerals, especially
iron and especially for girls. Iron
deficiency and iron deficiency anaemia
are the leading causes of adolescent
disability-adjusted life years (DALY)
lost by girls aged 10–19 and boys ages
10–14 (one DALY can be thought of as
one lost year of ‘healthy’ life). Despite
improvements in South Asia, rates of
iron deficiency and associated anaemia
there remain the highest in the world,
followed by sub-Saharan Africa.81
After iron deficiency, iodine deficiency
is the second most common form of
hidden hunger among adolescents.
Global iodine status improved between
2003 and 2017, with the number of
iodine-deficient countries decreasing
from 54 to 19 and the number of
countries with adequate iodine intake
increasing from 67 to 111.82 Although
the DALY rate has gone down across
regions from 1990 to 2015, progress
has slowed in recent years.
Overweight, obesity and associated
NCDs are increasing among adolescents
in most regions of the world.83 While
rising trends have plateaued in many
high-income countries, although at high
levels, they have accelerated in parts of
Asia. Losing weight is hard. A child who
becomes obese during adolescence
is likely to remain so into adulthood
and to face higher risks of NCDs such
as type 2 diabetes. There is some
evidence that obesity in adolescence
can have lifelong negative effects on
the brain, contributing to early onset of
cognitive dysfunction during ageing.84
Pregnancy brings its own set of
nutritional vulnerabilities. Each year,
around 16 million adolescent girls
aged 15–19 give birth. Most come
from disadvantaged backgrounds
and, as such, often have inadequate
nutritional status before conception;
as nutrient requirements increase
during pregnancy, these risks are
compounded.85 Pregnant adolescents
are at increased risk of malnutrition due
to the competing growth and needs of
the foetus.86 Studies have shown that
adolescent pregnancy carries a greater
risk of complications and stunting of
a girl’s growth while also leading to
a higher risk of health complications
around the time of childbirth.87 Negative
consequences for offspring are much
greater for early adolescent pregnancies
(younger than age 16) than for late
adolescent pregnancies (aged 16–24).88
Catch-Up Growth
The rate of physical growth during
adolescence is rapid, second only
to that in early childhood.91 Healthy
nutrition is vital in this period, and some
evidence suggests that rapidly growing
teens can even gain back some of the
linear growth deficits suffered in early
childhood, a phenomenon known as
‘catch-up growth’. Typically, stunting
prevalence decreases with age – that is,

SPOTLIGHT
In search of healthy habits in Indonesia
It’s 8am and the sun is already scorching the sports yards
in front of a high school in Klaten District, Central Java,
Indonesia. There’s basketball practice on one side and ten-
nis on the other, but not everyone is joining in. “I don’t like
doing sports outside, there’s so much dust, and it’s hot!”
Zahfa giggles. Judging by the number of her classmates
chatting in the shade, she’s not alone.
For many of the students, this sports class is the only
physical activity they do all week. Their school day is long
and does not give them time to exercise. Nor does it en-
courage healthy eating habits – students arrive at 6.45am
and classes continue, with a few rest breaks, until late
afternoon, which partly explains why missing breakfast is
so common.
According to a 2017 UNICEF study, around half of Indo-
nesian teenagers miss or skip daily breakfast at home, so
their first meal of the day is made up of whatever they can
get at school.89 There’s typically no regulation on what can
be sold in school canteens, so what’s available is largely
left to the discretion of the school or vendors. Typically,
Zahfa at school in Klaten District, Central Java, Indonesia. © UNICEF/Indonesia/2018
02 | FEEDING A CHILD FOR LIFE » SPOTLIGHT » 87
the school curriculum also includes little about nutrition
and healthy activities.
Factors such as these, as well as wider changes in diets
(such as increased consumption of unhealthy foods) and
industrialization have helped double rates of overweight
in adolescents between 2004 and 2013. Indonesia has
traditionally focused on reducing undernutrition, which
remains a major problem – around 30 per cent of children
under 5 have stunted growth.90 Nevertheless, amid rising
overweight, there’s increasing awareness of the need to
improve the knowledge, attitudes and behaviours of ado-
lescents, their families and communities on healthy eating
and physical activity.
That also means integrating nutrition and physical educa-
tion messages into the school curriculum for students like
Zahfa. “At home, I just watch TV,” she says, “or I hang out
with my friends, eating and chatting in the café.” Although
she does try to get to the gym once or twice a week, it’s a
challenge to fit it into her day. “School finishes at 4pm, so
if I go to the gym, I don’t get home until 6pm. It’s tiring.”¢
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To a teenager, the
future can seem
too abstract and
far away to worry
about the long-term
effects of what
they eat
some children who were stunted early
achieve normal stature by adulthood.92
The potential for catch-up growth
depends on many factors, including
the severity of stunting experienced
and the external environment during
adolescence. Some evidence
suggests that children who experience
catch-up growth perform better on
cognitive tests than their stunted
peers who do not catch up.93 Despite
these promising findings, the
physiological mechanisms underlying
catch-up growth are complex, and
measurement is difficult.94 More
evidence is needed on the extent
to which physical and cognitive
deficiencies can be eliminated.
While adolescence may provide an
opportunity to catch up, gaining weight
too rapidly in this period also poses
risks. Children who are undernourished
usually reach puberty at a later age,
as the body delays sexual maturation,
allowing more time for growth.95
Yet studies from Kenya and Senegal
have found that when a stunted teen
gains weight quickly, for example
after moving from a rural area to a
city or being adopted into an affluent
environment, it triggers earlier puberty,
so closing the ‘window’ for growth.96
Good nutrition is critical to support
the increased biological demands
of adolescence. While prevention of
stunting in the first 1,000 days remains
a priority, adolescence provides a
second window of opportunity for a high
return on investment with nutritional
interventions. For some children,
catch-up growth means a second, and
perhaps final, chance to overcome
the deficits suffered in early life.

BOX 2.2 | Eating disorders, diet and adolescent mental health

Concern over body size and physical appearance, rapid
bodily changes, societal pressure for thinness, dieting and
peer pressure all make adolescence a time of increased
vulnerability to eating disorders.
The risk of developing an eating disorder is influenced by
both genetic and environmental factors. Eating disorders run
in families, and over 50 per cent of liability of developing an
eating disorder is due to genetic factors.97 Societal pressures
to be thin in girls, and to have low body fat and high
muscularity in boys, can lead to behaviours that may be
the first step in a slippery slope toward eating disorders.98
Other mental health problems seen in adolescence such as
depression, anxiety and low self-esteem are also associated
with eating disorders.99 Eating disorders are more common
in girls, but in part this is because they may be under-
detected in boys.100 Healthcare professionals may fail to
recognize the symptoms of eating disorders in boys because
they assume they are female-only disorders.
In addition to eating disorders, both healthy diets and
food availability play a role in adolescent mental health.
According to a study in the United States, among
mothers, past-year food insecurity – lacking access to
enough food for a healthy, active lifestyle – increases
the risk for childhood behavioural problems (aggressive
behaviours, anxiety/depression, and inattention/
hyperactivity).101 Mental health outcomes associated
with food insecurity are not limited to childhood.
Multiple US studies have reported an increased risk of
past-year diagnoses of mood, anxiety and substance
misuse disorders among adolescents reporting past-
year food insecurity, independent of other aspects of
socio-economic status.102 Indeed, these associations have
been reported in other countries, continuing in college
and through young adulthood, highlighting the global
importance of having adequate, healthy food available
across all phases of development for both physical and
mental well-being.103 ¢

Adolescent food choices
To a teenager, the future can seem
too abstract and far away to worry
about the long-term nutritional and
health effects of what they eat.
Health and nutrition are simply not a
major influence on the diets of many
adolescents.104 Instead, external
factors, such as disposable income to
spend on snacks and fast food, peer
pressure and the social desire to fit
in among friends, body image issues,
and food marketing can all play a role
in influencing what adolescents eat.
Casual work and pocket money from
parents provides irregular income,
particularly in middle- and high-income
countries, and is often used to buy
unhealthy snacks.105 As one teen in
Iran says, “Sometimes I decide to
start eating healthy, but then in the
morning I see my mom hasn’t prepared
me a healthy snack and instead gives
me money to buy snacks. Then it is
natural that I go for buying things such
as crisps and puffed cheese.”106
Body image affects food choices
as well. Depending on the local
context, many adolescent boys want
to gain weight and muscle mass,
while many girls can be concerned
about either excess weight or gaining
weight as a sign of well-being and
attractiveness. Eating disorders are
not limited to high-income countries.
Among young Tanzanian women aged
15–23, eating disorder symptoms
increased with media exposure.107
Marketing, packaging and aspirational
status symbols have a seductive pull
on all consumers, but adolescents
are especially influenced by these
factors. Fast food and prepared snacks
02 | FEEDING A CHILD FOR LIFE » 89
are widely available in urban areas
worldwide and can be especially
appealing to young people. Fast
food restaurants, with their clean,
bright interiors, are places where
teens can hang out with friends.
For example, in Guatemala, the
consumption of fast food and soft
drinks is a sign of higher social status
and upward mobility: “Being able to
eat fast food was perceived as a sign
that a family had middle- or upper-class
status. Adolescents in … rural areas
‘dreamt’ of eating fried chicken in fast
food restaurants, and adolescents
from poorer economic backgrounds
looked forward to consuming soft
drinks on special occasions … They
indicated that they purchased snacks
because of the taste (‘it just tastes
good’), notions about the food (‘it gives
us energy’), and peer pressure and
social acceptance (‘we all buy it’).”108
Conclusion
Each stage of childhood produces
specific nutritional needs, eating
behaviours and influences on diet.
But whether it’s not breastfeeding
exclusively in the first few months,
not eating a diverse diet in the early
years, or consuming too much sugar,
salt and fat during the adolescent
years, children are not eating the diets
they need in order to grow healthy,
and this has lifelong consequences. The reasons why
The reasons why children are children are
malnourished at different ages reflect a malnourished at
combination of drivers at the individual, different ages reflect a
family and broader societal levels. combination of drivers
Widening our lens of analysis beyond at the individual,
each stage of childhood reveals the family and broader
many causes of malnutrition.¢ societal levels
90 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

SPECIAL SECTION

What is a healthy diet?

What should children eat? It’s a simple question, but for many parents and caregivers,
and even children themselves, the answer is not straightforward. The exact make-up
of a healthy diet depends on each individual and local contexts, but the basic principle
of a healthy diet is one that contains fruits and vegetables, whole grains, fibres, nuts
and seeds, and during the complementary feeding phase, animal source foods. Healthy
diets limit free sugars, sugary snacks and beverages, processed meats, saturated and
industrially produced trans-fats and salt.109

Ninety countries have developed food-based dietary
guidelines, often based on recommendations from
international organizations, into clear, understandable
dietary advice that can also be visualized to aid
communication.110 However, these guidelines are
often not specific to the different phases of children’s
development and rely on recommendations that
are not harmonized globally. Countries also struggle
to provide clear guidance in the context of rapidly
changing modern food environments, with ultra-
processed, packaged foods taking up more of
children’s daily diet. Dietary recommendations can
also become politicized, with food producers pushing
back if government recommendations urge the public
to eat less of their products. We have remarkably
little data on dietary intakes and food consumption
patterns over time, which also affect the design and
updates of such guidelines.
Most national dietary guidelines advise eating a varied
diet of four to five food groups:
†† fruits and vegetables (up to half of daily diets in
many cases)
†† whole grains and starchy foods
†† healthy, lean proteins and dairy foods
†† limited intake of sugar, fat and salt.
Across all child age groups, energy intake should
be in balance with energy expenditure to prevent
overweight and obesity. While a common guideline of
an adequate diet applies throughout childhood, there
are specific recommendations for birth to age 2:
†† Exclusive breastfeeding from the first hour of life
until 6 months of age, and continued breastfeed-
ing until age 2
†† Nutritious and safe complementary (soft,
semi-solid and solid) foods should be progres-
sively introduced starting at 6 months, with a
particular emphasis on a diverse range of iron-
rich, nutrient-dense foods without added salt,
sugar or fat, such as lean animal-source foods
(including eggs, meat, fish and dairy), fruits and
vegetables, and legumes, nuts and seeds.
Debates about public health nutrition in the media
and among policymakers have often been influenced
by controversies, fads and lobbying by business-
interest groups, with arguments often based only
loosely on the scientific evidence, or misinterpretation
or over-simplifying of the evidence. This can result
in a muddying of the evidence that undermines
policymakers’ confidence to take action. Controversies
over conflicts of interest in nutrition research funding,
especially when provided by the food industry, have
added to the public’s confusion over what makes up
a healthy diet. For example, industry-funded research
investigating the health impact of sugar-sweetened
beverages is overwhelmingly and consistently more
likely to reach ‘weak/null’ conclusions compared with
independent studies.111 A lack of conflict-free funding to
implement evidenced-based dietary recommendations
and nutritional interventions limits the broad impact
of dietary guidelines. Past nutrition policy and
programmes have often relied on ‘knowledge’ as the
driver of behaviour change, assuming that better dietary
choices will be made through education and dietary
guidelines. Knowledge alone is not enough to improve
dietary intake, however, and broader policy, behaviour
change and environmental strategies are needed,
especially given low investment by governments
 02 | FEEDING A CHILD FOR LIFE » SPECIAL SECTION » 91

Cooked rice, vegetables, meat and beans are portioned for children into small bowls at the ‘Baby Café’ in Pandas Village in Klaten District, Central Java Province.
Parents and grandparents come to the Café each morning to buy food prepared by ‘cadres’ (volunteer community health workers). ‘Cadres’ help improve children’s
nutrition by providing information and counselling to their mothers. © UNICEF/UN04263/Estey

in public education and communications campaigns
compared to the food industry’s investment in marketing.
Even if they have nutritional information, consumers may
choose unhealthier but tastier, less expensive or more
convenient foods that are marketed to them.112
In recent years, Brazil has provided some common-
sense public recommendations based on what and
how people actually eat on a daily basis. Researchers
looked at the available data and saw that people were
cooking less at home and eating more processed,
packaged foods, leading to nutritional problems
such as overweight, obesity and diet-related NCDs.
According to the University of Sao Paulo’s Carlos
Monteiro, whose Center for Epidemiological Studies in
Health and Nutrition helped develop the guidance, “the
more people used the ready-to-consume products,
the more problems they had with the diet … people
who preserve that pattern of having freshly prepared
dishes had the best diet. The good news is that these
people are not the richest. They have lower income,
many of them live in isolated places in Brazil.” The
recommendations provide guidance on what and how
to eat (encouraging more cooking and eating with
others at home) with one ‘golden rule’: always prefer
natural or minimally processed foods and freshly made
dishes and meals to ultra-processed foods.113, 114
While our understanding of what makes up a healthy diet
for children has advanced in recent years, gaps remain
in defining the optimal intake for children at specific
ages and for those living in different geographic regions
and in different food environments. Unlocking further
understanding through funding and research can put in
place better evidence-based dietary recommendations
and effective nutritional interventions at scale.¢
92 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
Scholastica Nguli
Founder,
Rondo Women's
Development
Organization,
Tanzania
Scholastica Nguli, the
founder of the Rondo
Women’s Development
Organization (ROWODO),
has worked since 2011 to
reduce child deaths caused
by malnutrition in the
Rondo area of Lindi region,
Tanzania. ROWODO is a
member of the Partnership
for Nutrition in Tanzania
(PANITA), a collection of 300
civil society organizations.
PERSPECTIVE
Women lead the way in community-based
child nutrition in rural Tanzania
In Africa, rural, remote villages are often
synonymous with poverty and malnutrition,
but this is not the case for the small village
of Rondo in south-eastern Tanzania, where
women have simply refused to watch their
children die or suffer from stunting. Instead,
they have been educating their communities
to adopt a lifestyle of healthy eating. They
walk up to 7 kilometres conducting door-to-
door calls on families or to give talks at health
centres where women usually congregate.
These women are undertaking these
life-changing activities in addition to their
demanding daily chores such as tilling the
land, fetching firewood, preparing food for
their families and taking care of their children.
Because a lack of awareness of breastfeed-
ing is one of the factors behind the burden
of child malnutrition in the Rondo area,
Rondo Women’s Development Organiza-
tion (ROWODO) decided to spread their
knowledge to healthcare facilities through
household visits and public meetings to
ensure that nutrition is placed high on the
agenda – and ultimately to end hunger,
achieve food security, improve nutrition
and promote sustainable agriculture.
ROWODO faces a range of challenges
that impair efforts to stop malnutrition. The
first is cultural beliefs. Most communities
in Rondo restrict breastfeeding soon after
their child is born, throwing out breastmilk
because they believe it is dangerous to
their babies. This restricts babies’ intake
of important vitamins from their mother’s
first milk after birth.
Another challenge is the lack of gender
equality. Since most of the men do not
participate in domestic duties, mothers
have a heavy workload, for example going
to the well to fetch water, going to the
forest to find firewood, preparing food for
the family and cleaning the household.
Because these mothers are so busy, child
feeding is negatively affected.
There is also a problem of giving children
food other than breastmilk before the age
of 6 months. When a child cries repeated-
ly, many women believe they are crying
because of hunger and that they are not
satisfied with breastmilk. They start to
give them porridge made from cassava
flour, which is not suitable. Many families
also go to traditional healers when their
child is suffering instead of the hospital.
This exacerbates malnutrition and the
increasing incidence of deaths among
children aged under 5 years.

To fight malnutrition in Rondo ward,
ROWODO:
†† educates mothers, either one-
on-one by visiting families or by
hosting talks at maternal clinics, on
the importance of exclusive breast-
feeding after giving birth, at least
until the baby is up to 6 months old
†† teaches parents about the dangers of
feeding babies under six months old
foods other than their mother’s milk
†† provides information on the impor-
tance of feeding infants up to 2 years
old with nutrient-rich food, such as
cassava, lentils, beans and grains such
as ulezi (millet) that are grown locally
†† breaks old myths, for example one
that says a pregnant woman should
not eat eggs.
02 | FEEDING A CHILD FOR LIFE » PERSPECTIVE » 93
© UNICEF/UNI197919/Schermbrucker
The women of Rondo have become
the epitome of taking action at a time
when most of society waits for gov-
ernment to fight malnutrition alone.
Often, communities see malnutrition
as too big a problem and feel that there
is nothing they can do to change it.
Yet the action by the women in Rondo
demonstrates that there are solutions
within the reach of communities to
end malnutrition.
All interventions count, whether it is
breastfeeding, washing hands before
eating, keeping a clean environment,
or drinking clean, safe water. There
is no one specific approach that
communities must adopt to help them
accomplish significant change. The
example of Rondo shows that collec-
tive action has a significant effect on
bringing malnutrition in a community
to an end.¢
03
MALNUTRITION
  IN A CHANGING
WORLD
 0 3 | M A L N UT R IT I O N I N A C H A N G I N G WO R L D » 95

Globalization, urbanization, climate shocks †† Globalization has changed

everything from crop
and emergencies are worsening the harvesting to supermarket
food displays. 77% of
processed food sales
nutritional prospects of millions of poor worldwide are controlled by
just 100 large firms.
and excluded children. For many, lack
of access to nutritious, safe, affordable
and sustainable food is compounded by †† By 2050, 70% of the world’s
adolescents will live in
the threat of disease from poor water cities, more exposed to the
marketing of unhealthy foods
and sanitation. We need a nutrition and more vulnerable to diet-
related diseases.

transformation to ensure these children

get the chance to fulfil their potential and
to help end the flow of poverty across †† Without action, future
generations will likely face
generations. increased food insecurity
and malnutrition brought
on by climate change.

Ruma, 10, picks spinach on the roof of her family’s shelter in the Kutupalong refugee camp in southeastern
Bangladesh. “We will eat it tonight for dinner,” she says. Her family receives food rations of rice and dal, but no
fresh vegetables. “My two favourite things right now are studying and playing. I am a good student. Now, I can
read. My dream is to become a language teacher.” © UNICEF/UN0331082/Nybo
96 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

Because of poverty Introduction nutrition of tens of millions of children,

and exclusion, the
greatest risk of all
forms of malnutrition
is shouldered by the
most disadvantaged
children
Across urban and rural contexts, poor-
quality diets threaten the survival,
physical growth, brain development
and life potential of poor and excluded
children, setting them up to pass
disadvantage down to the next
generation. Even in an ever-changing
world, this is as – if not more – accurate
today as it was decades ago.
The world has undeniably changed.
A growing body of evidence about
nutrition – on the importance of
maternal nutrition before and during
pregnancy, on exclusive breastfeeding
and diverse first foods, and on good
care and hygiene practices in early
childhood – is providing crucial
insights to pave the way for good
nutrition from the first 1,000 days into
middle childhood, adolescence and
adulthood and on to new generations.
Globalization, unplanned urbanization
and climate shocks are also driving
dietary changes, both positive and
negative, and these changes are
shaping families’ food options and
choices. Those who can afford it may
have greater access to diverse and
nutritious food, but for far too many,
these benefits remain out of reach.
Because of poverty and exclusion,
the greatest risk of all forms of
malnutrition, and, consequently, the
heaviest non-communicable disease
(NCD) risk burden is shouldered by
the most disadvantaged children.
Emerging science
Nutritious food is necessary to
ensure children grow well, but it’s not
sufficient. Around the world, diarrhoeal
and other diseases undermine the
as do less well understood conditions
such as chronic inflammations
of the gut. Increasing evidence
shows that poor diets are harming
children’s gut flora, raising their risk
of infection, and that intergenerational
cycles of malnutrition can also be
the outcome of both maternal
underweight and overweight.
Greater knowledge in areas such
as hygiene and sanitation, the
microbiome and epigenetics has
the potential to prevent disease and
poor nutritional outcomes from the
first 1,000 days into adulthood.
Hygiene and sanitation
Malnutrition underlies 45 per cent of
deaths in children under 5 years of age.
Diarrhoea is particularly deadly when
children are undernourished, killing
over 700 children under 5 every day in
2016.1 Most childhood cases can be
traced back to unsafe drinking water,
foods contaminated in the home, or
faecal contamination from poultry
and livestock. Improper sanitation
helps spread infectious diseases and
intestinal worms and encourages the
development of conditions such as
environmental enteric dysfunction.
Our understanding of the role of
hygiene and sanitation in malnutrition is
evolving. For example, recent research
suggests that much higher levels of
hygiene and sanitation are needed to
safeguard children from stunting than
was previously thought: “Conventional
thinking is that improving access to food
and educating families about hygiene
will prevent childhood malnutrition,
but these interventions keep failing,”
according to the lead author of a study
 0 3 | M A L N UT R IT I O N I N A C H A N G I N G WO R L D » 97

BOX 3.1 | Conceptual Framework of the Determinants of Maternal and Child Nutrition

When children and women eat well,
everyone benefits. Children provided
with a nutritious, safe and diverse
diet are equipped for the physical
and cognitive development, school
performance and healthy life that
awaits them.
For children to eat well at each stage
of growth, not only must food be
of good quality and consistently
available, accessible and affordable,
but several other factors must be in
place. Their families need resources.
These include money, but also
knowledge of how to access and
provide a healthy diet. They need
support in the face of financial stress
and time pressure. They need access
to quality health services and a
healthy environment, free of disease
and unsanitary conditions.
Children’s diets are also determined
by broader forces at play, such as
political commitment, economic
priorities and social norms.
To better understand and address
these complex and far-reaching
challenges, UNICEF has developed
the 2020 Conceptual Framework of
the Determinants of Maternal and
Child Nutrition. It builds on UNICEF’s
1990 framework on the causes of
child undernutrition, acknowledges
the evolving and multiple nature of
maternal and child malnutrition, and
incorporates new knowledge on the
drivers of malnutrition.
The Conceptual Framework uses
a positive narrative about what
contributes to improving maternal
and child nutrition and preventing
malnutrition in all its forms in
children, adolescents and women. It
provides conceptual clarity about the
enabling, underlying and immediate
determinants of maternal and child
nutrition, and about the outcomes
resulting from improved nutrition
in children, adolescents and women
(see below). The Framework guides
U N IC EF ’s 2020 –203 0 Glob a l
Strategy for Maternal and Child
Nutrition.¢

Outcomes IMPROVED NUTRITION FOR CHILDREN AND WOMEN Children’s

for children
diets are also
Improved survival, health, physical growth, cognitive development, school readiness and
and women school performance in children and adolescents; improved survival, health, productivity
and wages in women and adults; and improved prosperity and cohesion in societies.

determined
Immediate GOOD DIETS GOOD CARE
by political
commitment,
determinants for children and women for children and women

ADEQUATE FOOD ADEQUATE FEEDING HEALTHY ENVIRONMENT

economic
Underlying
Breastmilk, nutrient-rich
age-appropriate foods, with
Age appropriate and responsive
feeding and stimulation, with
Healthy food environments,
quality health, nutrition and priorities and
safe drinking water and adequate food preparation, sanitation services, and a
determinants household food-security,
at all times
food consumption, and
hygiene practices
healthy living environment,
including for physical activity
social norms

GOOD GOVERNANCE POSITIVE NORMS

Political, financial and multi-sectoral Social and cultural commitment
commitment to advance children's and to advance children’s and women’s
Enabling women's right to nutrition right to nutrition
determinants
SUFFICIENT RESOURCES
Environmental, financial, social and human resources
to fulfill children’s and women’s right to nutrition

Source: UNICEF. Maternal and Child Nutrition UNICEF Strategy 2020–2030. UNICEF: New York; 2019
98 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Children washing their hands in a
refugee camp in Betou, Republic of the
Congo. © UNICEF/UN0327817/Diefaga
in rural Gambia.7 “There’s a very high
threshold of hygiene necessary to
allow children to grow properly –
communities need improved living
conditions and access to clean
water piped into their homes.
These findings should redirect
governments’ priorities, shifting
efforts to providing drastically
better housing, and better
access to clean water.”8
Food safety
Contamination of food – whether
from the environment or from
microorganisms – has dire implications
for children’s health. Infants and
children are especially vulnerable to
such threats because their metabolic
system is still developing and key
organ maturation is susceptible to
permanent and lifelong disruption. 9
 0 3 | M A L N UT R IT I O N I N A C H A N G I N G WO R L D » 99

BOX 3.2 | Environmental enteric dysfunction

The deleterious effects of acute diarrhoea on health are well
known, yet in otherwise healthy populations, and those in
which interventions have reduced diarrhoea, many children
still do not achieve normal growth.2 The exact cause of this
growth failure is unknown, but there’s increasing interest in
the possible role of environmental enteric dysfunction (EED).
EED is a subclinical disorder where chronic exposure to
faecal pathogens inflames and damages the intestines,
reducing the body’s ability to absorb nutrients. It is strongly
associated with stunting and iron deficiency.3 The condition
is highly prevalent among people living in conditions of
poverty.4 Biomarkers for EED are found in children living
in unsanitary household environments and are associated
with high levels of stunting.5
EED may also play a role in poor cognitive development and
educational achievement among children. A longitudinal
study in eight low- and middle-income countries found an
association between a higher number of enteric infections
and poorer cognitive scores at 2 years of age, independent
of diarrhoea.6 ¢

The best preventative measure for
infants, who are especially vulnerable
to foodborne and waterborne
disease, is breastfeeding.
Parasites, viruses and bacteria – such
as Salmonella and E. coli – naturally
inhabit the surfaces of raw food and
can cause serious illness. Without
good hygiene practices such as regular
handwashing with soap, the improper
handling of food in preparation or
storage can result in foodborne illness.
The impacts of contamination via
water, air or soil and exposure to
antibiotics and pesticides have been
well documented in recent years
and, in high-income countries in
particular, have resulted in a demand
for organic and pesticide-free foods.
Researchers and the scientific
community are also examining the
effects of exposure to food additives
and substances in contact with foods
in its packaging, for example, plastics.
The microbiome
Often called the body’s ‘second
brain’, the gut microbiota has been
the subject of growing research and
attention in recent years. Its powerful
effects on physical and mental
health are becoming increasingly
clear, as is its role in enhancing
immune system functions.
Our bodies are home to trillions of
microbes that play an instrumental
role in nutrition and healthy growth.
These tiny intestinal guests not
only metabolize the food we eat
and affect our weight and cognitive
development,11 but also strengthen
our immune systems. They even
predict our vulnerability to developing
diseases, including obesity.12
By the age of 3, children have
established most of their microbiome
for life.13 Whether the microbiome
begins to develop during pregnancy or
childbirth is still a matter of debate, but
the first hours, days and years of life
are critical. In childbirth, microbes from
the birth canal and vagina are passed
to the baby, inducing an important
immune response. Breastfeeding and Contamination
skin-to-skin contact starting in the first of food has dire
hour help create a healthy microbiome. implications for
Breastmilk contains proteins, human children’s health
10 0 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Microbes tell the milk oligosaccharides and probiotics that
body whether it improve health and brain development.
needs a particular Breastmilk has been called “probably
type of food, the most specific personalised
through what’s medicine that the child is likely to
known as the receive, given at a time when gene
‘gut–brain axis’ expression is being fine-tuned for life.”14
Threats to this development include:
exposure to antibiotics (in utero
or in early life), birth by caesarean
section, formula feeding and lack of
diversified first foods. These disrupt
microbiome establishment and can
adversely affect nutrition and health,15
for example by increasing a child’s
vulnerability to allergies and asthma.16
Adding diversified first foods to
an infant’s diet after the first six
months of life adds bacterial variety
that helps digest fibre, starch and
proteins. A more diverse diet helps
the microbiome perform a greater set
of metabolic tasks. Adequate, largely
plant-based diets high in fibres and
proteins create healthy microbiomes.
By the same token, eating processed
foods that are high in sugar, salt, fat
and additives affects the microbiome
BOX 3.3 | Additives
In the United States, an estimated 10,000 chemicals
are allowed in food and its packaging, yet considerable
knowledge gaps exist on the safety of these chemicals.
The American Academy of Pediatrics (AAP) released
a policy statement in 2018 asking for reforms to how
food additives are regulated. It highlighted concerns
over bisphenol A (BPA), phthalates, perfluoroalkyl
substances, perchlorate, artificial food colours and
nitrates/nitrites, given their links to endocrine
disruption, attention-deficit hyperactivity disorder
in ways that can encourage obesity,
diabetes and inflammatory bowel
disease.17 For example, some
additives in foods such as mayonnaise
and ice cream break down the
protective barrier of mucus in the
gut that separate microbes from
the intestinal lining and produce
proteins that inflame the gut.18
The gut microbiome also influences
our food choices. Research shows that
microbes communicate with the brain,
telling the body whether it needs a
particular type of food, through what’s
known as the ‘gut–brain axis’. This
might start even in breastfeeding, when
the infant’s needs are communicated to
the mother via contact between saliva
and the nipple in a feedback loop.19
There is still much to learn about the
microbiome’s role and development
during the early years. For example,
little is known about the gut microbiota
of children in the first two years
of life in low- and middle-income
countries. More research is needed
also on links between mothers’
microbiomes during pregnancy and
childbirth and infant stunting.20
(ADHD), and chronic conditions such as cancer, type
2 diabetes and obesity.
In addition to better testing, closing data gaps and
labelling additives, the AAP also recommend reducing
exposure by eating more fresh or frozen fruits and
vegetables, avoiding processed meats, handwashing
with soap before handling food, washing fruits
and vegetables, and avoiding putting plastic in a
microwave or dishwasher.10 ¢
 0 3 | M A L N UT R IT I O N I N A C H A N G I N G WO R L D » 101

BOX 3.4 | Epigenetics

Epigenetics is the study of changes in organisms brought
about by modifications in gene expression. It is a change
in phenotype (observable physical and biochemical traits)
without a change to genotype (the inherited genetic
composition of a cell, i.e. DNA). In other words, a person’s
environment or lifestyle can change which genes in
their DNA sequence are expressed or not expressed,
and that change can be passed down to their children.
For example, maternal micronutrient deficiencies can
alter foetal metabolism and organ development, resulting
in epigenetic changes in the child. This epigenetic
adaptation puts children at increased risk of childhood
overweight or obesity, and chronic diseases in adulthood,
including obesity, coronary heart disease, stroke and
type 2 diabetes.22
How does this happen? Put simply, the baby of an
undernourished mother ‘expects’ a low-nutrient
world. However, fed a diet high in calories (and low
in nutrients), the child becomes predisposed to some
forms of disease.23 ¢

Intergenerational cycles have shown an association between

of malnutrition
A mother’s health and nutritional
status is key to determining that of her
child (see Chapter 2). Both maternal
undernutrition and maternal overweight
affect children’s development, including
that of their metabolism, “fueling an
intergenerational cycle of malnutrition.”21
Much more research is needed on the
complex impacts of maternal – and
paternal – nutrition on children, especially
in emerging areas such as epigenetics.
Amid growing global rates of obesity,
increasing attention is being paid to the
negative effects of maternal overweight
and diabetes on health and nutrition
outcomes for the mother herself and
for her child and future generations.24
Today, maternal overweight 25 is the most
common risk factor of pregnancy.26
The association between maternal
overweight and a child’s risk of metabolic
disease is remarkably strong across the
life course. Studies from around the world
maternal overweight and overweight in
the next generation at the ages of 21, 32
and even – according to the Helsinki Birth
Cohort Study – 62. That same study also
found links between maternal overweight
and children’s physical and psychosocial
functioning in late adulthood. 27, 28
At the same time, examples of rapid
improvements in tackling undernutrition
– from Japan, South Korea and more
recently Brazil 29 and Peru 30 – show
that nutritional status can dramatically
improve even within a single generation.
A 2013 study of children in their first
two years from Brazil, Ghana, India,
Norway, Oman and the United States
also concluded that, with adequate
care and nutrition, children of parents
who experienced adverse nutritional
conditions can still attain optimum
height. 31 To ensure that happens,
women and girls – and especially
adolescent mothers – need support Both maternal
and guidance on nutrition before undernutrition and
pregnancy, for their own well-being overweight fuel the
and so as not to miss the window of intergenerational
opportunity of the first 1,000 days. cycle of malnutrition
10 2 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

SPECIAL SECTION

Girls and women need stronger

support for better nutrition
As primary caregivers, women play a pivotal – if not the most crucial – role
in whether children are eating well, yet far too many women are excluded
from decision-making. They face early marriage and early pregnancy as girls,
intrahousehold discrimination and domestic violence, restrictions to their
education and employment opportunities, and gender-biased laws that limit their
access to land and financing. What is more, far too many girls and women struggle
with malnutrition themselves.

Poor diets are amplifying gender imbalances by
reducing learning potential, increasing reproduc-
tive and maternal health risks and lowering pro-
ductivity. These impacts are perpetuating inter-
generational cycles of malnutrition and inequity:
the children of malnourished mothers are more
likely to suffer stunting, cognitive impairments,
weakened immunity and a higher risk of disease
and death.
Adolescent girls are especially vulnerable to mal-
nutrition because they are experiencing their fast-
est physical growth since the first years of life.
With menstruation, their bodies require more
iron. Adolescent pregnancy – a major contributor
to maternal and child mortality – presents par-
ticular risks because girls’ bodies have not fin-
ished growing and the foetus might compete for
nutrients.
Women are more vulnerable to micronutrient
deficiencies, particularly iron deficiency anaemia.
This unmet nutritional need for iron is linked to
the greater likelihood of being poor, and lacking
power and access to resources. Malnourished
mothers confront major risks. These include a
compromised immune system, greater risk of
dying in childbirth, lower productivity and capacity
to generate income, and greater difficulty in
caring for their families.
When girls and women are denied the right to
food, nutrition and health, children, households,
communities and economies suffer. Converse-
ly, when they are empowered to achieve higher
levels of education, control more income, bring
assets home and to make decisions, nutrition
improves and everyone benefits, setting a virtual
cycle in motion.
Women face a disproportionate work burden.
While more likely than men to work as unpaid
family labourers or in the informal sector, they
also make up nearly 40 per cent of the world’s
formal labour force.115 Yet, almost everywhere,
mothers remain responsible for most child
feeding and care.
As mothers increasingly take on new roles –
as entrepreneurs, academics and community
leaders, for example – many grapple with time
poverty. The time and energy demands of
multiple roles can make for a stressful, if not
impossible, challenge to feed their children, and
themselves, well. Without the support of their
partner or family network – and without access to
affordable, healthy foods – they may rely on the
convenience of processed foods or fast foods.
Along the same lines, without the right workplace
practices or national policies in place, mothers
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Chantal, a tea plucker on the Rutsiro Tea Plantation in Rwanda, has four children. Before the plantation’s early childhood development centre was built,
Chantal would carry her daughter, Umuhoza, now 3, on her back all day when she worked. "It was very uncomfortable to pluck tea while carrying our
children. We were also very unproductive because we had to stop and breastfeed and care for our children. We knew we were not giving them the best
opportunities, but we had no choice. After the centre was built, we had more time. Our children are now doing well and we are more productive." In 2017,
UNICEF Rwanda partnered with the National Agricultural Export Development Board to help tea plantations and factories be more family-friendly work
environments. This includes advocating for paid maternity leave and breastfeeding breaks, flexible working hours for new parents and affordable child care
options. © UNICEF/UN0308986/Rudakubana

might not be able to exclusively breastfeed
or continue breastfeeding. Despite three ILO
Conventions on Maternity Protection – the first
was 100 years ago – most countries have made
only slow progress in adopting policies to support
breastfeeding.
To address this requires raising women’s social
status, autonomy and decision-making power. It
requires enabling girls to stay in school longer to
achieve better livelihoods and independence. It also
requires investing in adolescent girls’ and women’s
nutrition and health, with a particular focus on the
pre-pregnancy, pregnancy and lactation periods.
To make the right nutrition decisions, women and
mothers need adequate information, counselling,
support and access to nutritious, safe, affordable
and sustainable foods. They need maternity
protection policies so that workplaces support
exclusive and continued breastfeeding, and enough
paid parental leave. A recent study recommends a
minimum of six months’ paid leave to ensure the
best outcomes for mothers and children (this aligns
with the WHO recommended duration for exclusive
breastfeeding).116 Gender-equitable parental leave
policies that encourage fathers to use leave are
also associated with reduced family stress, more
involved parenting and more stable relationships.¢
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77 per cent of Globalization on food security. However, from the

processed food
sales worldwide are
controlled by just
100 large firms
Globalization – the flow of goods,
technologies, information, capital and
more across country borders – has
overtaken food systems. It has changed
everything from the harvesting of
crops to the way food is displayed in
a supermarket to what children eat.
On the one hand, families who can afford
it have access to a greater availability
and diversity of food – quinoa, kimchi
or year-round strawberries. On the
other hand, with the expansion of
ultra-processed and fast foods and the
impact of marketing, multinational and
transnational corporations are making it
increasingly hard for children to eat well.
The rise of supermarkets, convenience
stores and fast-food chains around the
world reflects changes in both consumer
demand and the supply of low-nutrient
foods to consumers, including children
and their caregivers. A quarter of a
century ago, food supplies tended
to be under the control of national
governments, which focused heavily
mid-1990s, food was included in world
trade agreements. The result is that
food systems are now exposed to
business forces that have changed the
availability, price and marketing of foods.
While there are millions of farmers,
food producers and consumers,
there are only a few large processors
and marketers: 77 per cent of
processed food sales worldwide are
controlled by just 100 large firms.32
As the High Level Panel of Experts on
Food Security and Nutrition points out
in its 2017 report, “The progressive
concentration of much of the economic
power in the hands of transnational food
corporations over the past decades
has limited the domestic policy space
and political power of local and national
governments. In turn, this has reduced
governments’ ability to protect and
promote the right to adequate food
of their people.”33 The same report
highlights that “those most impacted by
inequitable, dysfunctional food systems
and unhealthy food environments include

BOX 3.5 | Ultra-processed foods

Processing of food is not in and of itself undesirable.
Many popular, traditional and nutritious foods are
‘processed’ – think of drying wheat or fruit or making
yoghurt. However, not all food processing is the same,
and nutrition specialists typically make a distinction
between ‘processed’ and ‘ultra-processed’ foods. The
latter have been defined as “industrial formulations”36
containing little or no whole foods, but rather
substances extracted from whole foods, for example
“hydrogenated oils and fats, flours and starches,
variants of sugar, and cheap parts or remnants of
animal foods usually with little nutritional value
compared to the original whole food.”37 These foods
are energy dense, high in fat, sugar and sodium, and
low in fibre and micronutrients – think of burgers,
nuggets, cookies and sugary drinks.
Avoiding ultra-processed foods is not easy; nor are
they designed for moderate consumption. Thanks to
their high levels of fat, sugar, salt and other flavours,
many ultra-processed foods taste delicious and feel
satisfying in the mouth. Also, taking into account
their heavy marketing – often aimed at children (see
Chapter 4) – and wide availability, it is easy to see why
such ultra-processed items displace fresh or minimally
processed foods.¢

low-income consumers, the rural and
urban poor, smallholder and subsistence
farmers and indigenous peoples.”34
On the demand side, economic and
climate forces are moving people to
urban areas where lifestyle, socio-
cultural pressures and marketing are
changing diets (see ‘Urbanization’ below).
The increasing availability and growing
market share of ultra-processed foods,
for example, presents a tremendous loss
for traditional food markets, small-scale
farmers and rural populations who can’t
compete with the big businesses or
supermarket chains. In some cases, this
is pushing rural families to move to urban
areas in search of better livelihoods.
For some children, this means greater
access to education, healthcare services
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and diverse foods. For others, urban life
means dietary threats (greater exposure
to fats, sugars, salt, etc.), sedentarism,
environmental pollution and unsanitary
or overcrowded living conditions.
Ultra-processed foods are at the heart
of the globalization of food markets. As
markets in high-income countries have
matured, global or transnational food and
beverage businesses have increasingly
sought out new markets in low- and
middle-income countries, including
sub-Saharan Africa, which represents
an “amazing opportunity”, as the head
of one fast-food business has said.35
Many of these businesses focus on ultra-
processed food items because their low
A street lined with market stalls in
production cost, long shelf-life and high Freetown, Sierra Leone.
retail value make them highly profitable. © UNICEF/UN072187/Phelps
10 6 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
The lack of public As a result, such foods are now almost
spaces drives ubiquitous, and found even in remote areas
adolescents to of Ethiopia and Nepal, where a choice
meet at fast-food of vegetables, fruits and fish is not.38
chains instead
Some experts have argued that because
the distribution chains of transnational
food companies now reach so far into
rural areas, urbanization is no longer
the main factor in determining whether
or not people, including children,
have access to unhealthy foods.39
A recent global analysis of trends in mean
body mass index (BMI) segregated by
rural and urban areas from 1985 to 2017
found that in low- and middle-income
regions (and with the exception of women
in sub-Saharan Africa), adult BMI is
increasing at the same rate or faster in
rural areas than in cities. The authors cite
the possible reasons as less energy spent
on daily work and domestic chores, and,
with increased incomes and a widening
availability of food products high in fat,
salt or sugar, increased consumption of
low-quality calories40 – in short, what has
been called “the urbanization of rural life.”41
Urbanization
Since the mid-20th century, the share
of the world’s population living in
cities has risen from 30 per cent to
more than half. Urban dwelling is only
set to grow, significantly affecting
children and young people. In 2009,
around half the world’s adolescents
lived in cities; by 2050, that proportion
is forecast to rise to 70 per cent.42
A common narrative is that dietary
changes are happening first in urban
areas, as are the consequent nutritional
outcomes and increase in NCDs.43 One
reason for this is the change in lifestyle
and environment. Compared to those
in rural areas, urban residents rely less
on starchy carbohydrates and tend to
consume more meat and other proteins,
more fruits and vegetables (among
richer households), more food outside
the home, and more ultra-processed
foods.44 The result is a higher prevalence
of overweight and obesity among city
dwellers. From Sri Lanka to India, from
China to Benin, urbanization is also
associated with high rates of diabetes,
hypertension and cardiovascular disease.45
City life accounts for some of these
trends: more sedentary jobs, less
time and energy spent on domestic
chores and greater use of public
transport to get around, which can
mean reduced physical activity.
For children living in cities, spaces for
outdoor play might be hard to find or
unsafe. This is important because children
who get more exercise are less likely to
be obese,46 not only because exercise
burns calories, but also because it
changes how the body processes glucose
and also likely benefits mental health and
helps combat depression. The lack of
public spaces for children to play or for
adolescents to convene also drives them
to meet at fast-food chains instead.
Buying food
Families living in cities typically buy their
food, so income is a key factor in what
they eat. They are more likely to buy
their food from large retailers, such as
supermarkets, and much of it is packaged
and processed or ultra-processed.47
Research from Kenya shows that people
shopping in supermarkets buy fewer
unprocessed staples (fresh fruits and
vegetables, etc.) and more processed
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SPOTLIGHT
Child nutrition in poor urban areas of Kuala Lumpur
In the low-cost flats of Kuala Lumpur, Rohana, Noor and
Siti Fatimah are three mothers with a common struggle:
providing their children with a nutritious diet. During a
focus group discussion held for the SOWC report, they
shared their main challenges.
Malaysia bears a significant double burden of malnutri-
tion: while 20.7 per cent of children under five suffer from
stunting and 11.5 per cent from wasting, 12.7 per cent of
children (5–19-year-olds) are obese.118 This reality is more
complex in poor urban areas, where malnutrition rates
tend to be higher than the national average.119
Affordability is a common problem. While all three mothers
understand the importance of eating nutritious food, cost
constraints determine what they can feed their children,
regardless of its nutritional value. The cheapest and most
typical meal consists of fried eggs, rice and soy sauce.
Noor, mother of four explained, “I do not think about that
thing [healthy and balanced food)]. Others are eating fish,
but I am able to provide only rice. I know it’s not good, but
that’s all I can provide.”
Poor-quality diets are both physically damaging and
psychologically distressing. One mother said that she
might only have the chance to serve chicken once a
Siti Fatimah peels boils eggs to put in curry at her home in Desa Rejang, Setapak, Kuala Lumpur. © UNICEF/Zahri 2019
year. Another mother acknowledged that eggs are easy
to obtain, but one of her children is allergic to them,
so she is obliged to find alternatives. A third mother
received a report that her child attempted self-harm
because the child was not able to eat at a famous fast-
food chain.
Meal frequency is also a major concern. Sometimes, they
must purchase their groceries on credit at the nearby
shop. Noor and Siti Fatimah explained that they ration the
food among their children throughout the day. Otherwise,
they will finish the food too quickly.
Balancing work and household activities is also an im-
portant issue. While two of the three mothers were able
to achieve flexible working arrangements with their em-
ployers, Noor has to take her infant with her to work. This
slows her down and impedes her work performance, ulti-
mately affecting her income.
All three mothers expressed a strong desire to escape
poverty. To develop her business, Rohana explained, she
would benefit from policies that provide support to single
mothers. Noor and Siti Fatimah agreed. With access to
start-up capital, they too would like to open a business of
their own.¢
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Television and ultra-processed food items.48
commercials for This is also seen in Thailand, where
snacks and supermarket shopping is associated with
sugary drinks consumption of soft drinks, snack foods,
target children processed meats and instant foods.49
Children and caregivers in cities also
experience more exposure to the
marketing of processed foods, which
can influence food choices.50 Such
marketing is seen in public city spaces –
including near schools – and in television
commercials for snacks and sugary
drinks, for example, that target children.
For the urban poor, such as those living
in slums, eating well proves even more
challenging as access to nutritious
foods narrows. Many rely heavily on
street food, which is often high in fat
and salt. Street food accounts for about
a quarter of household food spending
in low- and middle-income countries.51
Food-insecure households in urban
areas of Malawi, for instance, were more
likely to consume processed foods from
street vendors. One study concluded
that “Food insecure urban residents may
be especially vulnerable to poor health
outcomes associated with both poor
access to nutrient-dense foods and diets
high in refined and processed foods.”52
Cities are taking action to address these
challenges. As of July 2019, 198 cities
around the world signed the Milan
Urban Food Policy Pact with the aim to
“develop sustainable food systems that
are inclusive, resilient, safe and diverse,
that provide healthy and affordable
food to all people”.53 The NOURISHING
Framework also brings together policy
action across food environments, food
systems and behaviour change. From
Curitiba,54 Amsterdam, Daegu and Dakar
to London,55 city-level action includes
improving access to healthy foods for
poor households, introducing school-
based advocacy and learning, urban
farming, and enforcing restrictions on
the marketing of unhealthy foods.
Access to healthy food
Not everyone has access to healthy
foods. For families in rural and remote
areas, or areas with poor infrastructure,
limited physical access to healthy
food outlets can be compounded by
issues around access to farmland
as well as climate and seasonal
fluctuations, which can threaten
food security and diet diversity.56
In our increasingly urbanized world,
families in cities also face major
challenges in finding healthy foods.
Many live in ‘food deserts’ – mostly
urban neighbourhoods where residents
have little or no access to healthy food
markets.57 In these communities, people
may buy food from fast-food outlets and
unexpected places such as petrol (gas)
stations, barber shops, gyms, discount
stores, hardware stores, local general
shops and laundromats.58 The abundance
of high-calorie, low-nutrient, processed
foods in these areas has also led to the
more descriptive term ‘food swamp.’59
Because they offer an abundance of
nutrient-poor, ultra-processed, fatty and
sugar-sweetened foods (and limited
or no options for healthy food), food
deserts and swamps are by their nature
obesogenic environments and have been
found to strongly predict obesity rates.60,
61
The high prevalence of food deserts in
low-income, minority and underserved
neighbourhoods 62 also means that the
already vulnerable and disadvantaged
children living in these areas face
increased risks of suffering overweight,
obesity and the lifelong burden of NCDs.

SPOTLIGHT
Childhood obesity: An urgent concern for China
Amid rapid economic growth and
urbanization, China has experienced
a remarkable shift in malnutrition
since 1985. While the rate of stunting
among school children declined from
16 per cent in 1985 to 2 per cent in
2014, rates of overweight and obesity
increased from 1 to 20 per cent.68
China is now home to one of the
largest groups of obese children
worldwide. 69 In 2015, the Global
Burden of Disease reported over 15
million obese children (aged 2–19) in
China.70 The Chinese Center for Dis-
ease Control and Prevention put the
total population of both overweight
and obese at 120 million in 2012.71
Boys are at greater risk of suffering
overweight and obesity than girls:73
21 versus 12 per cent, according to a
2018 study among 9–11-year-olds.74
Overweight and obesity are also more
prevalent in wealthy households,75, 76, 77
and rates are significantly higher among
schoolchildren in urban areas, although
this disparity is narrowing and has even
converged in some affluent areas.78, 79
Overall, the children at greatest risk of
being overweight or obese are only-sons
from wealthy, urban households.
FIGURE 3.1 | Prevalence of stunting, thinness and overweight among children (7–18 years old) in China, 1985–201472
1995
Note: Stunting, thinness and overweight are defined according to WHO anthropomorphic definitions.
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Why is this happening?
Many factors have led to the rise in
overweight in China. Rapid economic
development, urbanization and tech-
nological advancement have brought
changes in lifestyle and behaviour.
These are evident in decreased phys-
ical activity among children, togeth-
er with a shift in diet away from the
traditional cuisine that is rich in plant
foods and grains prepared at home,
to a modern diet high in meat, sugar
and fried foods, and often consumed
in snacks or away from home.80, 81
Consumption of sugar-sweetened
beverages (SSB) also plays a role.82
Decreased physical activity – without
decreased food intake – puts chil-
dren at risk of overweight. In 2006,
the Chinese Government launched
a national programme, Hundreds
of Millions of Teenagers Sunshine
Sports, which aims to provide 85
per cent of schoolchildren with
more opportunities for exercise and
physical activity. In line with the
WHO recommendation of at least 60
minutes of moderate-to-vigorous
physical activity each day, 83 physical
education was added as one of four
2000 2005 2010
components of a students’ ‘all-round’
development.
However, a 2010 analysis of students
aged 9–18 years old showed that only
23 per cent were meeting the WHO
recommendation. Physical activity
was lowest among children with a
heavy homework burden,84 possibly
reflecting a traditional idea in Chinese
culture that ‘to be a scholar is to be
the top of society’.85 This means that
children routinely sacrifice play in
favour of academic study.86
Another cultural idea at play is the
tendency to perceive plumpness as
a symbol of wealth, high social sta-
tus and good health. Providing food
is a family’s top priority and children
are likely to be overfed, especially in
families where grandparents play a
major role as caregivers.87
In response to the alarming rates
of overweight and obesity among
children in China, China C entral
Government has emphasized the
urgent need for interventions and
actions in their National Nutrition
Plan (2017–2030) and Healthy China
Action (2019–2030).¢
Overweight
Thinness
Stunting
2015
11 0 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
As children grow, Although food deserts and swamps have
they develop typically been identified in high-income
lifelong countries, they are increasingly found
eating habits in low- and middle-income countries
experiencing rapid urbanization and food-
systems transformation. For example,
in urban parts of Brazil, Honduras,
Peru63 and South Africa, food deserts
are seen in communities facing a high
degree of poverty, and racial, ethnic
and income inequality.64 In Mexico,
where obesity prevalence ranks among
the highest globally, food swamps are
a bigger problem than deserts.65
Growing up in a food desert has serious
implications for a child’s nutrition and
well-being. First, if families have less
access to fruits and vegetables, young
BOX 3.6 | Food prices and nutrition
A recent study of global food prices indicates that healthy,
nutrient-dense foods, especially animal-source food (ASF)
and fortified infant cereals, are much more expensive (on
a per-calorie basis) than starchy staples and unhealthy
processed foods in low-income countries.
This global study, led by the International Food Policy
Research Institute, set out to discover how relative prices
differ across countries and regions, and whether these
differences explain child feeding practices and stunting
prevalence.
The study compared the relative caloric price of a wide
range of healthy and unhealthy foods to the caloric cost of
the cheapest staple food in each country (e.g. rice, wheat,
cassava or maize). For example, a relative caloric price of
5 for eggs implies that it costs five times more to obtain
a calorie from an egg than to obtain a calorie from rice.
In high-income countries, ASFs are relatively cheap, at only
one to four times more expensive than starchy staples. By
contrast, in low-income regions of Asia and sub-Saharan
children may have no choice but to eat
diets lacking in diversity during a period
of critical development. Second, as
children grow, they develop lifelong eating
habits. This means that even if access
to healthy food improves, diets may
not: in the United States, for example,
the opening of a new grocery store in
a Philadelphia food desert increased
awareness, but did not alter dietary
intake or obesity in the community.66
In countries such as South Africa,
Botswana and Zimbabwe, the urban
dynamics are very different, with large
numbers of highly mobile residents
as well as informal economies and
prominent gender disparities. Yet while
the dynamics differ, evidence supports
Africa, which have the highest rate of stunting, ASFs can
be very expensive. In sub-Saharan Africa, calories from
eggs, milk and fortified infant cereals are around nine to
ten times more expensive than starchy staples.
The study findings indicate that countries with higher
relative prices of ASF and fortified infant cereals have much
lower consumption of those foods by infants and young
children, and much higher stunting rates. This suggests
that improving the affordability of these foods is a key
pathway to addressing the global burden of undernutrition.
The study also sheds light on why obesity rates increase
with national income. Oils/fats and sugar are very cheap
in all regions. However, sugar- and fat-rich processed
foods are often expensive in low-income countries, but
their prices decline rapidly as countries reach middle-
and upper-income levels. Unhealthy processed foods are
also cheaper sources of calories than healthy foods in
many poor countries, which may explain the dual-burden
phenomenon of rising obesity in the midst of persistent
undernutrition.91 ¢

a similar conclusion: the mere presence
of a supermarket may be insufficient to
improve nutrition if other aspects of the
food environment are not adequate.67  Ghana, foods rated as healthiest by
Cost
Cost is a contentious issue. There is
debate, for example, over whether healthy
foods are more expensive than unhealthy
foods – healthy foods can cost less in
purely price terms, but that advantage
can be outweighed by things such as the
time costs of preparing food from scratch.
Despite this, it’s clear that cost is a real
obstacle that prevents many families
from eating a diverse range of nutrient-
dense foods. This is especially true
for the poorest families, who have to
spend a bigger share of their income on
food. In the Democratic Republic of the
Congo, for example, research shows
0 3 | M A L N UT R IT I O N I N A C H A N G I N G WO R L D » 111
that the cost of nutrient-dense foods A girl crosses a puddle on
a flooded road in Maputo,
is a significant barrier to diversifying Mozambique. Yvonne, whose
young children’s diets,88 while in home is pictured here, lives
with fourteen family members
and makes a living selling
caregivers are generally also rated the vegetables from the stall.
© UNICEF/UN0139437/Prinsloo
least accessible due to their cost.89 In
the United States, higher costs (both
in terms of price and preparation time)
and less access to healthy foods in the
neighbourhood help drive differences
between richer and poorer families’
consumption of fruit and vegetables.90
Overall, poorer families tend to select
low-quality food that costs less.92 This
might suggest that as incomes rise,
families eat better. Unfortunately, this is
not always the case. Research shows
that when families – urban or rural –
spend more money on food, it is for
both healthy and unhealthy foods,93 and
that a rise in income produces increased
spending on convenience foods.94
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The impacts of
climate shocks fall
heaviest on the
poorest families,
who are both the
worst affected and
least able to cope
There may be several explanations for
this counter-intuitive result.95 Factors
beyond affordability and price – such as
convenience, exposure to marketing,
physical access to healthy food, level
of nutritional knowledge and cultural
factors – may make obesogenic foods
more desirable. Also, if women do not
control the additional income, it may not
be directed to the needs of the family
or child. Alternatively, other underlying
determinants of child malnutrition – such
as food safety – may remain unchanged.
As food systems continue to transform,
increasing income alone will not be
enough to address today’s triple
burden of malnutrition. Knowledge
constraints, gender inequities, unfair
marketing practices and other elements
of the food environment and food
supply – together with finding ways
to reduce the cost of healthy foods
– will all need to be addressed.
Climate shocks
Children disproportionately suffer the
impacts of climate change and environment
degradation. In the immediate aftermath of
a flood or typhoon, for example, children
are the most at-risk group for waterborne
diseases, such as those accompanied
by diarrhoea, and which heighten their
risks of malnutrition and death.
Sustained undernutrition and loss of
agricultural productivity, together with
families’ livelihoods, also threaten children’s
growth, development and learning, and can
lead to ‘distress migration’.96 These impacts
fall heaviest on children from the poorest
families, who are both the worst affected
and least able to cope.97 The cumulative
effects of prolonged or recurrent climate-
related disasters and variability are
often passed to the next generation of
children, perpetuating and deepening
cycles of intergenerational inequality.
Floods, storms, drought and extreme
heat around the world have collectively
doubled in number since 1990, with
devastating results.98 New crises,
floods and drought have resulted in
an increase of 11 per cent in people
facing food insecurity since 2016.99
Climate-related disasters cause severe
food crises: drought is responsible for
80 per cent of damage and losses in
agriculture,100 dramatically altering what
food is available to children and families,
as well as its quality and price. This is
true in both rural areas – for small-scale
food producers, agricultural labourers and
families who buy their food – and urban
areas, where resulting food price hikes
determine what food is accessible.
Impacts of food production on the
environment and on children
Industrial food production plays a
major role in the environmental effects
of climate change and environmental
degradation because of its tremendous
ecological footprint and contribution
to emissions and pollution. In addition,
the heavy use of fresh water, fertilizers
and pesticides also presents risks to
children’s nutrition and well-being.
Greenhouse gas emissions
Food systems account for up to
one-third of greenhouse gas (GHG)
emissions globally, according to a 2012
study.101 For example, the increasing
production of meat is one of the largest
sources of methane.102 If current trends
towards meat-heavy diets continue,
 0 3 | M A L N U T R I T I O N I N A C H A N G I N G W O R L D » S P O T L I G H T » 11 3
SPOTLIGHT
Climate change threatens child nutrition in Bangladesh
Over 19 million children spread across Bangladesh are at
the frontline of climate change disasters, a quarter of them
under 5 years old. Floods and riverbank erosion are driving
families to city slums, where they face overcrowding and a
lack of access to healthy food, education, adequate health
services, sanitation and safe water. In slums, children must
often fend for themselves and are at greater risk of malnu-
trition, child labour, child marriage and exposure to pollu-
tion, violence and abuse.
Extreme climatic events such as drought and flash floods
cause severe agricultural losses. In a country where over 60
per cent of the population depend on agriculture for their
livelihood, this means that children from the poorest fami-
lies are most likely to go hungry. Reductions in production
also lead to an increase in food prices, hitting the poorest
families hardest.
A rise in communicable and non-communicable diseases
linked to changing climate conditions and unplanned urban-
ization also threaten children and their families. These in-
clude hepatitis A, cholera, dysentery, typhoid, dengue and
chikungunya fever.117
Ruma, her husband, Ali Akbar, and their two children,
Sunjida, 3, and Shahaun, 9, moved to the Chalantika slum
of Dhaka after their home was repeated flooded by the
Meghna River. “At least we can stand on dry ground here
even if we struggle with the cost of living,” Ruma says.
A child wades through flood waters on her way to school in Kurigram district, Bangladesh. © UNICEF/UN0286416/Akash
“My husband earns about 7,000 Taka [US$83] a month. By
the time we have paid our rent and bought our groceries,
there is very little left over. But at least we are able to earn
here, which we often weren’t able to do when we lived in
the countryside.”
Ruma shares a small kitchen – a few planks of wood atop
bamboo poles set in a swamp – with at least 10 other
families. While they initially used butane gas, this proved
impossible to share equitably. Wood is now preferred, fur-
ther worsening the slum’s air quality. Her family eats rice
and lentils most days, she says, and can occasionally af-
ford meat or fish. Her son, Shahaun, is showing signs of
malnourishment.
In addition to the arduous challenge of trying to provide
her family with healthy food, Ruma describes an unhealthy
environment with no access to safe water, basic toilets or
adequate hygiene. Electricity in the slum is irregular, and
rodents and insects in their single room “make our lives an
absolute misery,” she says.
The Government of Bangladesh will begin the second
phase of its Climate Change Strategy and Action Plan this
year, placing greater emphasis on the needs of the poor-
est and most vulnerable, and demanding more attention
and resources to ensure that child nutrition, health, edu-
cation, sanitation and water, and social protection services
are shielded from the effects of climate change.¢
11 4 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
A chemical the environmental impacts of food
pesticide is up production on GHG emissions are
to 10 times more estimated to increase by 87 per cent.103
toxic to a child
than to an adult To benefit both people and the planet,
the EAT-Lancet Commission recently
proposed a dietary shift that doubles the
consumption of healthy foods such as
fruits, vegetables, legumes and nuts, and
halves that of less healthy foods such as
red meat and added sugar. The authors
note that given the unique dietary needs
of children, including for high-quality
protein, this “universal healthy reference
diet” is for children aged 2 and above.104
Food production also demands significant
use of fresh water, with water scarcity
already affecting children in every
continent.105 Further, fertilizers put
aquatic systems at risk of contamination,
and pesticides pose direct risks to
children.106 In addition to ingesting food
with pesticide residue, many children
are exposed to pesticides while
working in agriculture, which accounts
for 71 per cent of child labour.107
Pre-natal exposure to pesticides can
increase the risk of foetal death and birth
defects, while exposure in childhood
can disrupt the endocrine system, cause
cancer and delay neurodevelopment. A
chemical pesticide is up to 10 times more
toxic to a child than to an adult, and acute
poisoning usually results in death.108
Biodiversity loss
Together with climate change and
pollution, food production is also
implicated in the loss of biodiversity. A
recent UN report sounded the alarm on
the scale of the problem: nearly 1 million
species are threatened with extinction
due to human activities.109 Changes in
land and water use – for example, clearing
forests for large-scale crop or livestock
production systems – is recognized as
a major driver of biodiversity loss.110
Biodiversity is not only essential for
healthy ecosystems; it also directly affects
food security and nutrition.111 Children’s
dietary diversity is also at stake.112 With
less diversity in crop production, diets
are becoming increasingly homogenous
around the world (see Chapter 1).113
Just three crops – rice, wheat and
maize – now make up nearly two-
thirds of the global caloric intake.114
Without improvements to today’s dietary
patterns and food production, children,
their families and future generations are
likely to face greater risk of food insecurity
and malnutrition brought on by climate
shocks and environmental degradation.
Conclusion
The causes of child malnutrition are
more complex and far-reaching today
than they were in 1990. Sweeping
changes, seen in globalization, unplanned
urbanization and climate change, are
exacerbating already unfair outcomes for
the poorest and most excluded children
and their families. Worldwide crises
threaten to halt or reverse progress
in reducing child undernutrition.
At the same time, there is greater
acknowledgement that the exclusion
of certain groups from essential foods,
services, resources and decision-
making is unfair and avoidable – and
that children are paying the price.
Researchers, experts and practitioners
also recognize and are expanding the
evidence-base on the causes and risks

of malnutrition being passed from one
generation to the next. This knowledge
and attention have the potential to make
interventions more effective and to drive
action. Even so, more is needed in research
and practice to fully understand the
particular circumstances of children from
different population groups. For example,
few empirical studies exist on aspects
beyond poverty and gender. For a larger,
more sustainable impact, practitioners will
need to pay explicit attention to addressing
marginalization and gender inequities that
underpin disparities in the longer term.
If food systems are to transform and
deliver better diets for children, the
broader forces that affect children’s
0 3 | M A L N UT R IT I O N I N A C H A N G I N G WO R L D » 11 5
diets, growth and development –
resources, governance and norms –
will also require more attention (see
Chapter 4). They can be broken down,
examined and understood. Such
analysis reveals power structures in
food systems and where power is
exerted, which allows the nutrition
community and the public to leverage
and exploit spaces for change.
Such change is already happening in
many countries (see Chapter 4). With
greater coordination and implementation A girl carries a bucket of water
collected from a nearby dry river
of policies and programmes across bed in northern Kenya. Turkana is
the food, health, water and sanitation, one of the districts hardest hit by
prolonged drought and recurrent
education and social protection cholera. © UNICEF/UN0275168/
systems, it can be transformative.¢ Njuguna
11 6 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
SPECIAL SECTION
Nutrition in emergencies
UNICEF and its partners treated more than 3.4 million children with severe acute
malnutrition (SAM) in emergency contexts around the world in 2018. The greatest
numbers of children were treated in Afghanistan, Chad, the Democratic Republic of the
Congo, Ethiopia, Nigeria, Niger, Somalia, South Sudan, Sudan and Yemen. Almost 90 per
cent of the children recovered.120
In Sudan, as of April 2019, 11 of 18 states have global
acute malnutrition rates above the Integrated Food
Security emergency threshold of 15 per cent. While 2.4
million children under 5 suffer from wasting a year, close
to one third (700,000) of those suffer from SAM, with
high rates in Eastern Sudan and among South Sudanese
refugees.121
Historically, efforts to address nutrition in emergencies
focused largely on identifying cases of wasting – a
visual indication of severe acute malnutrition.122
However, the complexity and protracted nature of
crises have led to a global recognition that many
forms of malnutrition occur in emergency settings.
New evidence shows that these forms can include
stunting and micronutrient deficiencies.123 In
protracted humanitarian crises, the prevalence of
stunting is increasing, while rates of wasting continue
to be high.124 As a result, global nutrition leaders are
turning to approaches that combine short- and long-
term solutions to the problems of malnutrition.
Yemen
In Yemen, home to Moteab and his family, protracted
conflict, economic crisis and the dismantling of
essential services, including those for health and water
and sanitation, turned daily life into a “living hell”.127
His father’s job, transporting goods in a wheelbarrow,
provided the family with the bare minimum of food –
bread for breakfast, vegetables, usually potatoes, for
lunch and anything left over for dinner.
By the time Moteab turned 2 years old, the combination
of poverty and protracted conflict left him in a struggle
for his life. “He would throw up whatever he ate or
drank,” his mother said. After seven months of repeated
Tsahara holds her son, Moctar, 2, who is suffering from severe acute malnutrition. They have just visited the UNICEF-supported health centre in the village of Sarkin
Yamma Saboua, Niger, about 6 kilometres from their home village. © UNICEF/UNI122685/Asselin
These efforts focus on preventing avoidable deaths and
promoting growth. UNICEF and its partners conduct
nutrition assessments, identify and treat children, and
provide fortified foods and supplements to prevent
nutrient deficiencies. They also promote breastfeeding
and provide guidance on feeding infants and young
children, which can save lives in emergency situations.
Addressing nutritional needs in complex and protracted
emergencies involves partnerships around the world
that work to save lives and provide local and national
governments with the assistance they need to address
malnutrition in communities and to develop emergency
response plans during crises.
While 86 per cent of international humanitarian
assistance is distributed in countries experiencing
long- and medium-term crises, emphasis is increasingly
placed on resilience planning.125 Between 2005 and
2017, the average length of crises that received an inter-
agency funding appeal rose from 4 to 7 years.126
illnesses with vomiting, diarrhoea and weight loss, his
mother was directed to a free health centre in Abs,
where her son was diagnosed with SAM.
Moteab is just one of the 400,000 children in Yemen
who suffered from SAM in 2018.128 The humanitarian
crisis is one of the worst in recent history.129
In emergencies around the world, treating children like
Moteab involves tools and approaches to providing a
combination of routine medication, therapeutic foods,
individualized care and links to other social services
such as for hygiene and sanitation.130
 0 3 | M A L N U T R I T I O N I N A C H A N G I N G W O R L D » S P E C I A L S E C T I O N » 11 7
For example, in Yemen, partners employ the Standardized
Monitoring and Assessment of Relief and Transitions
(SMART), a methodology that allows for systematic
collection of reliable information that can be used to make
decisions and allocate resources to priority needs.
Community management of acute malnutrition (CMAM)
is also an important approach for addressing SAM in
emergencies around the world. In Yemen, by 2018,
UNICEF and its partners were supporting more than 3,300
outpatient therapeutic feeding programmes, such as the
one in Abs where Moteab received treatment.131
Though most children can be treated at home with ready-
to-use therapeutic foods (RUTF), Moteab’s condition
required treatment at a stabilization centre in Aslam,
one of 69 centres for children who experience health
Niger
In Niger, where the prevalence of stunting for children
under 5 is 41 per cent and anaemia is 77 per cent,132
doctors often treat SAM that is linked to preventable
disease. Dr Abale Laoali at the Intensive Nutritional
Rehabilitation Centre in Diffa explains, “Throughout
the country, the children who are severely wasted and
do not have access to adequate healthcare experience
higher rates of malarial infections. We’ve also observed
that children affected by malaria experience a decrease of
defences in their immune system. This makes them lose
their appetite, and to suffer from vomiting, pneumonia
or severe diarrhoea. At this point, the risk of severe
malnutrition is very high due to the lack of food, the
diseases, the poor health and hygiene conditions – and
displacement.”
One of Dr Laoali’s patients is 3-month-old Sani, diagnosed
with SAM, pneumonia, malaria and a congenital heart
complications in addition to SAM. However, as fighting
closed in on the area, Moteab was moved to Sana’a,
where he and his family were provided with the support
necessary for treatment in a therapeutic feeding centre at
a hospital.
For Moteab, the life-saving nutrition services he needed
were provided free to his family. They are services that have
set him on the path to recovery. “I can see improvement
since his admission to Al-Sabean Hospital,” his mother
says. “He has been receiving very good healthcare. He
now finishes the entire feed of the specialized milk that is
given to him and interacts with people around him.”
“I am happy,” she adds, “but I am worried about the other
children in our district that might reach my son’s situation if
they do not receive support and care quickly.”
disease. Two years ago, his mother Fatima fled Damasak,
Nigeria, a town held by Boko Haram, with her three
children. They have since been continuously displaced.
During her pregnancy with Sani, Fatima was anaemic
and suffered food insecurity and high levels of stress.
After arriving at the temporary site for displaced people
in Chetimari, Fatima brought Sani to the nearest health
centre. “The nurses told me that my little baby was in
danger because, in addition to malnutrition, he had
contracted malaria and pneumonia,” she says. “He didn’t
tolerate my breastmilk, he didn’t have any appetite and he
vomited a few times. I began to fear for Sani’s life.”
After 20 days of hospitalization and thanks to the guid-
ance of healthcare workers and support from partners,
Sani is breastfeeding again and has regained weight. His
malaria symptoms are gone and he is breathing without
the help of an oxygen machine.¢
11 8 U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
PERSPECTIVE
Sesame Workshop’s Raya teaches children
healthy habits
Sherrie Westin For 50 years, Sesame Workshop has
President, focused on a whole-child curriculum –
Social Impact and not only delivering the academic and
Philanthropy, socio-emotional lessons children need to
thrive, but also teaching critical skills in
Sesame Workshop
health and resilience.
Many children around the world suffer
from malnutrition, which can be caused
by a lack of access to healthy food and
by childhood illness. In fact, malnutrition
and preventable and treatable illnesses
such as pneumonia and diarrhoea are the
leading causes of death for children under
the age of 5.
We also know that our characters have a
great potential to talk to children, model
behaviours and provide the language to
talk about tough topics. That’s why we
created Raya, a special Sesame Street
Muppet. She’s 6 years old, with long braids
and a beaming smile – and she teaches
children in 11 countries, and 30 languages
life-saving lessons about water, sanitation
and hygiene (WASH) through our WASH
UP! initiative, in partnership with World
Vision.
and Raya We’ve seen encouraging results.
Global Health Independent research conducted with
Ambassador support from the Gates Foundation found
that our programme led to measurable
improvements in WASH knowledge,
attitudes and behaviours among children
in Bangladesh, India and Nigeria. Raya
and WASH UP! continue to inspire tens
of thousands of children to bring positive
change to their homes, schools and com-
munities.
As our ‘global health ambassador’, Raya
was the perfect companion to help
me with this piece. Thanks for chat-
ting with me today, Raya. I know you
know a lot about how to stay healthy!
Raya
I sure do! Like how important it is to
make sure water is clean before drinking
it. I tell my friends that one way you can
get sick is from tiny germs you can’t even
see. And how we all get germs on our
hands, so it’s important to wash them for
20 seconds with soap and water after we
use the bathroom and before we eat food,
to scrub those germs away!
Sherrie
What about your friends living where
there is no clean running water?
Raya
Lots of my friends around the world do
not have running water, but they still have
to wash the germs off. One fun thing we
make together is called a tippy tap. It’s
a hand-washing station people can build
anywhere – they’re easy to make and
use! And if you do have to go to the bath-
room outside, it’s really important to wear
sandals or shoes to the latrine to protect
your feet from germs too, because that’s
another way you can get sick.

Sherrie
That’s right, Raya. And when children get
sick, illness can prevent their bodies from
absorbing the nutrients they need to get
well, stay healthy and grow properly. That
can cause something called malnutrition.
Raya
So getting sick is the same thing as
malnutrition?
Sherrie
Getting sick is one of many reasons for
malnutrition. Malnutrition can also mean
not having enough food to eat, or not
eating enough of the kinds of nutrient-rich
foods that help children grow into healthy
adults.
Raya
I think I get it! I have a friend who taught
me about different kinds of food. You
know him too!
Sherrie
Are you talking about a certain blue, fuzzy
monster named …
Raya
Cookie Monster!
Sherrie
He does know a lot about his favourite
subject. What did Cookie Monster teach
you?
0 3 | M A L N U T R I T I O N I N A C H A N G I N G W O R L D » P E R S P E C T I V E » 11 9
Raya
He taught me and my friends on Sesame Sherrie Westin is
President of Social Impact
Street about the difference between and Philanthropy for
‘sometimes foods’ and ‘anytime foods’. Sesame Workshop, the
Cookies are a ‘sometimes food’, because non-profit educational
organization behind
they’re something we should eat only
Sesame Street. Westin
once in a while as a treat. But an apple leads the Workshop’s
is an ‘anytime food’ because it’s full of efforts to serve vulnerable
children through mass
vitamins and an important part of a healthy
media and targeted
diet. I can eat a delicious apple any time! initiatives. She serves
as Sesame Workshop’s
Sherrie chief mission ambassador,
raising awareness,
I love that Cookie Monster taught you developing strategic
something important about nutrition, and partnerships and
you’re telling other people like me about cultivating philanthropic
support to further the
it. Just like when you show children that
Workshop’s mission to
washing up is easy to learn. Children who help children everywhere
learn life-saving behaviours from you then grow smarter, stronger
and kinder.
teach their families.
Sesame Workshop’s
Raya global health ambassador,
Right! Healthy habits are contagious! Raya, is an energetic
6-year-old who’s guiding
conversations all over the
Sherrie world about clean water,
So you’re making an important difference handwashing and proper
latrine use. Raya always
in the world by helping so many children
remembers to wash her
stay healthy. Keep up the great work! hands with soap and water
and to wear her sandals
in the latrine to avoid
Raya
contracting illness. She
Thanks! I will!¢ encourages children to
share what they learn with
friends and family, making
good habits contagious.
04
 
RESPONSES TO
MALNUTRITION
 0 4 | R E S P O N S E S TO M A L N UT R IT I O N » 12 1

The evolving nature of global child †† A systems approach to

nutrition reflects the reality
malnutrition demands a new response: that child nutrition has
multiple determinants and
the shared responsibilities
one that can deliver nutrition-specific of multiple sectors and
stakeholders, public and
interventions and nutrition-sensitive private

development in a more coordinated fashion. †† Recent years have brought

growing momentum to
improve food systems,
The response must acknowledge the but the unique needs of
children have been ignored.
central role and responsibility of the food Children's needs must be at
the heart of food systems.
system, and work together with the health,
†† Nutrition-specific approaches
are also needed in four
water and sanitation, education and social key supporting systems –
health, water and sanitation,
protection systems to provide better diets education and social
protection.
for children.

Tuyisenge holds her 11-month-old daughter, Fabiola, while a community health worker measures her
mid-upper arm circumference at a UNICEF-supported care group growth monitoring session in Musanze
District, Rwanda. "Before I used only potato and beans, no other vegetables,” Tuyisenge says. “Now I
use all kinds of vegetables as well as small fish. I see the difference in the growth of my children."
© UNICEF/UN0301162/Noorani
12 2 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
A baby eats a piece of
bread while being carried
in the Hanaq Chuquibamba
community in Peru.
© UNICEF/ Vilca 2019
Introduction
For too long, nutrition was on the
periphery of the global development
agenda. In recent years, however, it
has gained greater attention, reflecting
growing recognition of the social and
economic benefits of investing in
nutrition. As the body of research on
effective interventions has expanded,
global policy discussions increasingly
focus on evidence-based approaches.1
The list of interventions is long, and
growing: from promoting breastfeeding,
to better supporting the poorest families;
from making labelling clearer and more
informative, to tackling iron deficiency
anaemia and other forms of hidden
hunger; from improving children’s
food environments, to making safe
drinking water available everywhere
– a huge array of actions can be taken
(and in many cases, are being taken)
to improve children’s nutrition.
Clearly, much more needs to be done.
Nevertheless, there are causes for hope.
More and more governments are laying
out strategies to improve nutrition. In
many countries, these represent an
important first step that can be built on in
the years to come. For these approaches
to make a real difference, governments
need to recognize three key realities.
• First, there are no easy fixes if
nutrition goes wrong in childhood.
The nutritional needs of children
are unique, and uniquely important.
That’s why children and young
people must be at the heart of
thinking around food and nutrition.
• Second, we need to meet
malnutrition challenges by working
across all relevant systems and
sectors. Food systems need to
better serve children’s needs, but
other systems – notably, those
for health, water and sanitation,

Nutrition and the Sustainable Development Goals
Source: www.un.org/sustainabledevelopment/hunger/
education and social protection – also
have crucial roles to play as part of a
coordinated and systemic approach.
• Third, while governments may be
at the forefront in setting policies,
strategies and programmes, they
cannot do it alone. Business and civil
society groups, as well as families,
children and young people themselves,
all have important roles to play.
How governments are
responding to a growing
momentum
In 2008, the Copenhagen Consensus
concluded that nutrition interventions
0 4 | R E S P O N S E S TO M A L N UT R IT I O N » 12 3
TARGET 2.1 UNIVERSAL ACCESS TO
SAFE AND NUTRITIOUS FOOD
By 2030, end hunger and ensure access
by all people, in particular the poor and
people in vulnerable situations, including
TARGET 2.1 infants, to safe, nutritious and sufficient
food all year round.
END ALL FORMS OF MALNUTRITION
By 2030, end all forms of malnutrition,
including achieving, by 2025, the internationally
agreed targets on stunting and wasting in
children under 5 years of age, and address the
nutritional needs of adolescent girls, pregnant
TARGET 2.2
and lactating women and older persons.
were among the most cost-effective
in development.2 That same year, The
Lancet published its landmark series
on Maternal and Child Undernutrition,
which highlighted the ‘golden window’
for nutrition in the first 1,000 days
after conception 3 (later followed by an
examination of the growing problem of
overweight).4 The momentum from these
critical conversations catalysed nutrition
as a global development priority, leading
to a number of global initiatives, including
the creation of the Scaling up Nutrition
(SUN) movement, a multi-stakeholder,
multi-sectoral approach to support country-
level strategies to combat malnutrition.
We need to meet
Building on the World Health Assembly’s child malnutrition
Global Nutrition targets, the UN Sustainable challenges by
Development Goals (SDGs) cast nutrition as working across all
a central input and outcome of sustainable relevant systems
12 4 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
163 countries now
have comprehensive
or topic-specific
policies, strategies
and plans that are
relevant to nutrition
and the promotion of
healthy diets
development. Goal 2 specifically calls
on Member States to “end hunger,
achieve food security, improve nutrition,
and promote sustainable agriculture.”
Indeed, 12 of the 17 SDGs contain
indicators that are crucial for nutrition.5
Adding to this global ambition, the United
Nations General Assembly proclaimed
the Decade of Action on Nutrition
(2016–2025), enhancing the global
commitment to eradicating hunger and
preventing all forms of malnutrition.
This growing global momentum
has spurred many governments to
update or develop new approaches
to nutrition. According to WHO, 163
countries now have comprehensive
or topic-specific policies, strategies
and plans that are relevant to nutrition
and the promotion of healthy diets.6
These signs of commitment are
welcome: however, there are reasons
to be cautious. First, many of these
policies are still nascent – one third
date from 2015 or later – so it will take
time to assess their impact. Second,
national nutrition policies do not always
fully incorporate goals, targets and
indicators related to the World Health
Assembly’s Global Nutrition Targets.
The incorporation of targets and
SMART commitments7 is fundamental
to ensuring that governments are
held accountable and that nutrition
interventions are effectively monitored. 8
Finally, there is evidence that nutrition
policies and programmes are still often
fragmented and uncoordinated.9
Scaling-up nutrition results
National approaches have increasingly
addressed nutrition concerns through
interventions in a number of traditionally
defined sectors, such as health and
education. Some of these interventions
can be thought of as direct, or nutrition-
specific, because they directly address
the immediate and some underlying
causes of malnutrition, particularly in
the most disadvantaged populations, for
example in breastfeeding counselling
or the early detection and treatment
of severe acute malnutrition (SAM).
Others can be thought of as indirect,
or nutrition-sensitive, because they
aim to address the basic and some
underlying causes of malnutrition, such
as through promoting social safety nets,
education and empowerment of women.
Nutrition-sensitive interventions boost
the effectiveness of nutrition-specific
interventions. In Brazil, for example,
a nutrition-sensitive social protection
programme utilizing conditional cash
transfers has reduced malnutrition-
related child mortality. Pregnant and
lactating women receive cash transfers
on condition that they attend pre- and
post-natal appointments and participate
in educational activities on nutrition
and health.10 Likewise, the education
sector provides a compelling entry
point for governments to address
malnutrition using a nutrition-sensitive
approach, particularly among the most
vulnerable. Pathways include helping
children develop healthy dietary habits
from an early age and improving the
nutrition literacy of adolescent girls.
The benefits of mixing nutrition-specific
and nutrition-sensitive approaches
across a range of sectors are clear.11
However, many actors remain focused
exclusively on nutrition-specific
approaches.12 And because of a lack
of coordination among actors and
sectors, efforts to promote better diets
for children and prevent all forms of
malnutrition are often falling short.

It is clear, then, that translating political
commitment to tackle malnutrition into
action requires more than just increased
attention; it also requires the mobilization
of government systems, institutions and
resources, and coordinated strategies.13
Success requires more than isolated
sectoral results – it requires a coordinated
systems approach in which food systems
themselves are transformed and other
key systems work together with the food
system to deliver nutrition results at scale.
Multiple responses to a
multifaceted challenge:
A systems approach
Why take a systems approach? First,
it better captures the importance of
the interactions and interconnections
across different areas, such as food,
health and education, and crystallizes
a common purpose: better diets and
better nutrition for children, adolescents
and women. Second, a systems
approach avoids the simplistic thinking
that malnutrition has straightforward
determinants that operate along linear
pathways. Instead, it puts the focus on
multiple, interconnected determinants,
and recognizes shared responsibility,
and the need to mobilize attention
and resources from a wider variety of
societal and governmental institutions.
Five systems in particular have crucial
roles to play. The food system must
respond and provide better dietary
choices for children, adolescents
and women. The health, water and
sanitation, education and social
protection systems are also fundamental
in driving transformation, particularly
in the personal and external food
0 4 | R E S P O N S E S TO M A L N UT R IT I O N » 12 5
environments, and delivering the
necessary services to support better
diets, practices and nutrition outcomes.
Achieving results at scale depends on
the robustness of these five leading
systems to implement nutrition-specific
and nutrition-sensitive interventions at
every stage of life (see Figure 4.1).
This is not to say that other systems
cannot also play a part. Information
systems, for example, are fundamental to
the collection, analysis and interpretation
of nutrition-related data, and can provide
the basis for timely and effective
decisions to improve nutritional outcomes
among children. Many countries have
different forms of information systems in
place to support nutrition interventions.
A systems approach targets the
key systems that have the ability to
deliver nutrition interventions at scale,
making them more accountable for
nutrition results beyond their sectoral
objectives. To give an example, in many
countries, nutrition is viewed as being
within the remit of the health sector,
which is given the main responsibility
for delivering nutrition interventions.
However, although the health system
is clearly an important pathway for
scaling up certain nutrition interventions,
many crucial determinants of child
malnutrition, such as diet diversity, are
well beyond its normal scope. Instead,
action is needed across multiple
systems to ensure quality coverage.
How and where this happens will vary
according to the context. Innovative
approaches to mobilizing systems for
improved nutrition are certainly needed. A systems approach
As the examples in this chapter show targets the key systems
(see Special Section), there is no shortage that have the ability to
of success stories and lessons learned deliver nutrition
that can help to show the way forward. interventions at scale
12 6 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

Multiple responses to a multifaceted challenge:

A systems approach to nutrition

Source: UNICEF. Maternal and Child Nutrition UNICEF Strategy 2020–2030. UNICEF: New York; 2019
 0 4 | R E S P O N S E S TO M A L N UT R IT I O N » 12 7

A systems approach
makes multiple
systems accountable
for nutrition results
beyond sectoral
objectives

The food The health The water and The education The social
system system sanitation system system protection system
includes all of the includes preventive comprises the policies, refers to formal and comprises a set of
activities and actors services as well as programmes, services, informal institutions public and private
involved in bringing curative care. It is facilities and actors designed to educate policies and pro-
food from production more than just service involved in providing children, from basic kin- grammes that aims
to consumption and delivery: governance, safe drinking water dergarten to secondary to prevent, reduce
through to disposal financing, supplies and and safe sanitation school. While public and eliminate economic
(see Chapter 1). This equipment, work- infrastructure. Policies schools are often the and social vulnerabilities
system includes inter- force and information often target the most primary consideration to poverty and deprivation.
mediate steps, such as systems are all integral vulnerable populations of education system Nutrition-sensitive
processing, distribution, parts of the health to address their basic policy, private schools social protection pro-
marketing and retail. It system. A strong health needs. A strong water can also follow national grammes can mitigate
is organized into four system supports family and sanitation system education guidance. A the effects of poverty
main parts: food supply practices, and produces is essential to ensuring strong education sys- on the nutrition of
chains, external food equitable survival, safe food, safe drinking tem has trained teach- children, adolescents
environments, personal growth and develop- water, and clean and ers, sound pedagogy, and women. A strong
food environments ment outcomes for healthy environments solid infrastructure and system combines
and the behaviours of children, adolescents for children, adoles- resources, and should different programmes,
caregivers and consum- and women. cents and women. be used as a delivery often focusing on the
ers with respect system to improve protection of vulnerable
to food. nutrition outcomes. groups, and breaking
the cycle of poverty.
12 8 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
SPECIAL SECTION
What does a systems approach
to nutrition look like in practice?
Meeting the malnutrition challenge requires action across five key systems: those for
food, health, water and sanitation, education and social protection. There are already
many examples from around the world of how each of these systems is helping to
support improvement in maternal and child nutrition.
Food system
Commercial fortification
of staple foods with mi-
cronutrients is one of the
most successful and cost-
effective interventions to
combat hidden hunger.
In the 1920s, Switzerland
and the United States started adding iodine to
salt, virtually eliminating goitre and cretinism – the
most severe forms of iodine deficiency disorders
– and paving the way for subsequent fortification
initiatives.14 Today, many countries routinely fortify
refined cereal grains with micronutrients.15
While technically simple, commercial fortification
requires cooperation between government agen-
cies and a mature food industry with centralized
and specialized processing and an adequate dis-
tribution infrastructure. It also requires monitoring
and quality control and is more effective when
paired with consumer education campaigns to pro-
mote consumption. Commercial fortification has
been widely successful in urban areas, where peo-
ple typically purchase food in central markets and
stores. It is more challenging in rural areas, where
the distribution infrastructure may be more patchy.
Universal salt iodization and
large-scale food fortification
Universal salt iodization is one of the great glob-
al nutrition success stories. Today, iodized salt is
available to 86 per cent of world’s households.
The result is that, between the early 1990s and
2016, the number of countries in which iodine
deficiency is a public health problem fell from
113 to just 19.16 This progress has led to a major
decline in iodine deficiency disorders and has
contributed to improving the intellectual devel-
opment of millions of children. Salt iodization
is also highly cost-effective, costing only about
US$0.05 per person per year.17
Following the success of salt iodization in devel-
oped countries, momentum gathered to scale it
up globally. In 1994, WHO and UNICEF endorsed
universal salt iodization as a safe, effective and
sustainable way to address iodine deficiency.18
However, salt iodization has made slow progress
in Southeast Asia and sub-Saharan Africa, espe-
cially in rural areas with poor infrastructure and in
countries that rely on small-scale salt processors.
As with any form of food fortification, success-
ful scale-up requires political commitment, en-
gagement from the food industry, and links with
national nutrition programmes and other develop-
ment priorities. Programmes also need to align
with changing dietary patterns. For example, the
increased consumption of salt through processed
foods, rather than as table salt, means that food
industries should ensure they use iodized salt.
Salt iodization is also compatible with WHO’s rec-
ommendation to reduce salt intake to less than
5g a day. By ensuring that all food-grade salt is
iodized, this limit can be safely met.19
 0 4 | R E S P O N S E S TO M A L N UT R IT I O N » S P E C I A L S E C T I O N » 12 9
Large-scale food fortification
The success of salt iodization paved the way for sub-
sequent fortification initiatives around the world. In the
United States, for example, salt iodization was followed
in 1933 by the fortification of milk with vitamin D to
prevent rickets and, in 1942, with the requirement to
add thiamine, riboflavin and iron to flour.20 In 1996, the
government mandated the addition of folic acid to flour
to reduce the prevalence of neural tube defects, the
most common of which are spina bifida and anenceph-
aly, a fatal condition. Subsequent assessments demon-
strated that the prevalence of neural tube defects had
decreased by 19–32 per cent. Numerous other coun-
tries have seen similar improvements.21 New national
flour fortification programmes are being considered,
including in high-income settings such as the United
Kingdom, where folic acid fortification is under review.22
Health system
Health facilities can play a ma-
jor role in improving nutrition
outcomes, but all too often,
these opportunities are missed.
For national health systems to
meet their full potential, they
need to deliver preventive ser-
vices and curative care, but
also to foster positive family practices, such as breast-
feeding, that can significantly scale up nutrition results.
Cambodia, Rwanda and India are three examples of
countries where the health system is taking on this role.
Cambodia has invested substantially in awareness-
raising in communities, as well as in improved quality
of care around the time of delivery. As a result the per-
centage of deliveries by a skilled birth attendant doubled
between 2005 and 2014 to 89 per cent in 2014, while
institutional deliveries increased from 22 per cent to 83 per
cent. Importantly, rates of early initiation of breastfeeding
rose more than tenfold between 1998 and 2014 to 63 per
cent.27 The programme has also helped stop the rise of
breastmilk substitute use among newborns.28
Rwanda has also made significant progress. It imple-
mented an intensive and sustained communication cam-
paign around feeding practices, including early initiation
of breastfeeding, and the Baby-Friendly Hospital Initia-
Currently 81 countries – from South Africa, Morocco and
Jordan, to Indonesia, to Mexico and Uruguay – mandate
fortification of wheat flour alone or in combination with
maize flour and rice.23 Even so, significant untapped po-
tential remains: if all countries worldwide fortified flour
with folic acid, this could prevent an estimated 230,000
cases of neural tube defects a year.24 Other obstacles
include the reality that national flour fortification stand-
ards do not always meet minimal requirements for key
nutrients such as iron, zinc and vitamin B12.25
As set out in the 2015 Arusha Statement on Food Forti-
fication,26 critical actions are still needed. These include
improved oversight and enforcement of food fortifica-
tion standards and regulations, better evidence to guide
policy and programme design, stronger accountability
and global reporting, continued advocacy, and additional
(albeit modest) investment.
tive. By 2014, skilled birth attendants assisted at 91 per
cent of deliveries, up from 39 per cent in 2005, including
at nearly all births in health facilities. The rates of ear-
ly initiation of breastfeeding also increased, from 64 per
cent in 2005 to 81 per cent in 2014.29 Rwanda now has
45,000 community health workers who counsel mothers
about adequate feeding practices and safe deliveries.
In India, national and state governments implemented a
multi-pronged strategy to support breastfeeding, includ-
ing large-scale programmes, effective capacity-build-
ing initiatives, strong partnerships, community-based
action, and communications campaigns. As a result,
early initiation of breastfeeding rose from 24.5 per cent
in 2006 to 44.6 per cent in 2014. The increase was even
greater – from 12.5 per cent in 2006 to 34.4 per cent
in 2014 – in the seven states with the highest rates of
newborn deaths.30, 31
These examples demonstrate how countries can inte-
grate and improve the quality of breastfeeding counsel-
ling within the health system to achieve results at scale.
All three countries were able to strengthen the capacity
of health workers and health facilities to deliver nutrition
interventions. These positive results demonstrate the
benefits of institutionalization, protection, promotion
and support of breastfeeding in maternity facilities, par-
ticularly in the first days of life.
13 0 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
Water and sanitation system
By causing conditions such
as diarrhoea and dysentery,
which prevent children
from absorbing nutrients,
poor water and sanitation
are major factors in malnu-
trition. Improvements in the
water, sanitation and hygiene (WASH) system,
combined with nutrition interventions, can therefore
play a critical role in preventing stunting and other
forms of malnutrition. Such approaches have been
adopted in Pakistan and Ethiopia, which both suffer
high rates of stunting – more than one third of chil-
dren aged under 5 are affected – and where access
to basic sanitation services is still a major national
concern.
In Pakistan’s Sindh province, UNICEF Pakistan and
its partners implemented an integrated package of
WASH and nutrition interventions focused on the
crucial first 1,000 days. The WASH activities fo-
cused on reducing the incidence and severity of
infection and controlling environmental enteropa-
thy, a chronic inflammation of the gut. Interven-
tions included maintaining safe water supplies,
encouraging community-based approaches to
eliminate open defecation, improving hygiene be-
haviour, and developing service provider capacity.
Challenges remain, but there has been sig-
nificant progress. Community health workers
Education system
School-based food and
nutrition interventions can
play a key role in creat-
ing an environment that
provides and promotes
healthy diets and nutri-
tion among children and
adolecents.33 By educating and influencing chil-
dren (and their parents) to make healthy food
choices, education systems can deliver not only
have been mobilized, and WASH clubs have
been formed in schools to empower children
to promote positive practices. In total, an estimat-
ed 922,000 children aged under 5 and women
have been reached with packages of nutrition ser-
vices, including micronutrient supplementation.
In Ethiopia, UNICEF implemented a Baby WASH
programme in 2017, with the aim of protecting ba-
bies and young children from microbial infections
during play and feeding. The programme includes
interactive communication for development tools
and materials, including a radio drama series, pub-
lic service announcements (PSAs), and discus-
sion groups with mothers.
The intervention has helped change behav-
iours. According to an internal evaluation report,
almost three quarters of those who listened
to the radio programmes and PSAs said they
had made changes. Around half said they
were washing their hands more often and us-
ing soap, while around a quarter had stopped
open defecation. Work has already begun
with the Ministry of Health to scale up the ap-
proach across the country, including the develop-
ment of national guidelines and a training manual,
and the launch of a national training initiative for
trainers who will implement the Baby WASH ap-
proach in the regions.32
nutrition-specific interventions but also ensure
nutrition-friendly environments.
In India, the adolescent anaemia control pro-
gramme shows how the education system can
work to scale up nutrition-specific results. The
programme began in 2000 with the launch of a
pilot targeting adolescent girls in 2,000 public
schools across five states. The pilot delivered
three main interventions: weekly iron–folic acid

supplementation, monthly nutrition and educa-
tion, and twice-yearly deworming. It benefited
8.8 million girls aged 10–19. After a year, the pro-
gramme reported a significant decrease in the
prevalence of moderate to severe anaemia.34
Based on the positive outcomes and lessons
learned, the Government of India launched the
national weekly iron and folic acid supplemen-
tation programme in 2012, targeting 116 million
adolescents aged 10–19, across 32 states. For
the first time, almost 40 million boys were also in-
Social protection system
Social protection pro-
grammes are a powerful
instrument to not only lift
families and children out of
poverty, but also to promote
maternal and child nutrition.
A range of interventions,
such as conditional and unconditional cash trans-
fers, food rations and school feeding, can all help
limit the long-term effects of deprivation and pro-
vide communities with the means to access and
afford nutritious food. Cash-transfer programmes,
in particular, have proven benefits for the nutritional
status and health outcomes of children.35
Social protection programmes have been widely
implemented in Latin America, and have helped
countries reduce poverty, promote food securi-
ty and improve nutritional outcomes for children,
young people and families. In Brazil, for example,
the Bolsa Familia (‘family allowance’) programme
launched in 2003 reached more than 13 million
families in its first decade of implementation, and
contributed significantly to social and public health
improvements.36 Specifically focused on nutrition,
the programme played a vital role in helping low-
income families to purchase food, thus enhancing
their dietary quality and diversity.37 Among chil-
dren aged under 5, the programme was crucial to
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corporated in the programme. By 2016–2017, the
national programme was reaching 36 per cent of
the targeted adolescents, and all states had
taken key steps to maintain the sustainability
of the programme. Co-led by the Ministry of
Health and Family Welfare, the Ministry of
Education and the Ministry of Women and
Child Development, the programme is a prom-
ising example of the sort of coordination among
different government institutions that is funda-
mental to building an effective education-system
approach to improving nutrition.
reducing child mortality, which is closely linked
to malnutrition. A study published by The Lancet
showed that Bolsa Familia was crucial to reducing
child mortality among children aged 5, by incen-
tivizing pre- and post-natal care and supporting
immunization campaigns and health and nutrition
activities for mothers and children.38
Similarly, Mexico’s conditional cash-transfer pro-
gramme, Prospera, has benefited around 7 mil-
lion families.39 Child nutrition has been a major
component of the programme from its inception.
Families included in the programme benefit from
regular maternal and child services where chil-
dren’s nutritional status is monitored. Nutrition
services aim to improve families’ capacity to eat
healthily and feed their children a nutritious, safe
and affordable diet. As studies have shown, the
programme has helped to promote nutrition and
optimum growth, and has also enhanced dietary
diversity among families and children.40, 41
These large-scale interventions prove the impor-
tance of nutrition-sensitive social protection sys-
tems, helping countries not only to mitigate the
effects of poverty, but also to strengthen families in
their childcare role, which is a fundamental aspect
of ensuring healthy eating habits and better child
nutrition.¢
13 2 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Food systems need
to be reshaped from
simply feeding
people to nourishing
people – especially
children – well
Putting children at the
heart of food systems
Effective food systems (see Chapter 1)
are fundamental to securing nutritious,
safe, affordable and sustainable diets
for all children, everywhere. Despite
their central role, however, food
systems have been largely absent in
policy and programming for maternal
and child nutrition. Fortunately,
attitudes and approaches are changing.
There is growing recognition in the
international community that food
systems need to be reshaped from
simply feeding people to nourishing
people – especially children – well.
An important early step in this thinking
came with the Rome Declaration
on Nutrition in 2014. Since then,
reports and studies have shed light on
particular aspects of food systems. 42
For example, a report by the High
Level Panel of Experts on nutrition
and food systems dives deeper into
the crucial role of food environments
in shaping dietary choices, as well
as the potential pathways in all
food systems – whether traditional,
modern or mixed – towards more
sustainable and healthier diets. 43
Among other insights, the role of key
stakeholders has been emphasized by
the Global Panel on Agriculture and
Food Systems for Nutrition,44 while the
Global Nutrition Report has underlined
the role of government and business in
ensuring that food systems and food
environments support healthy diets.45
Most recently, in early 2019, the EAT-
Lancet Commission highlighted the
need to accelerate the transformation
of food systems to achieve not only
the SDGs, but also climate goals.46
This momentum needs now to extend
to ensure that food systems meet the
needs of children and young people.
Given children’s unique nutritional
requirements, there is an urgent need
to put their needs at the heart of food
systems. Among key issues that need
to be considered are interventions
to improve dietary choices in food
environments, i.e., the points at which
children, young people and caregivers
interact with the wider food system,
such as stores, markets, restaurants
and fast-food outlets and marketing
and advertising. The roles of legislation
and regulation, and how business and
the private sector can better support
nutritious diets for children, are also vital
components of a systems approach.
Supporting food system
transformation through legislation
Legislation can play a fundamental role
in promoting better dietary choices
for children and young people at
various points in the food system,
such as by regulating the marketing
of unhealthy food to children and of
breastmilk substitutes to caregivers,
by levying taxes on unhealthy foods
to create price disincentives, and by
increasing demand for and access
to nutritious foods. It also creates a
level playing field for all companies.
The International Code of Marketing
of Breast-milk Substitutes (BMS),
for example, is a well-established
regulatory framework that protects
and promotes breastfeeding, while
ensuring the proper use of breastmilk
substitutes, when necessary, by
prohibiting their promotion and
ensuring adequate product labelling. 47
(Nevertheless, according to the
Access to Nutrition Foundation,

“The world’s six largest baby food
companies continue to market BMS
using marketing practices that fall
considerably below the standards
of the Code”.) 48 As of April 2018,
136 of 194 countries had at least
some form of legal measure in place
to address the provisions of the
Code. Several countries have also
made significant efforts to address
inappropriate marketing practices of
commercial complementary foods. 49
Despite these efforts, most countries
still lack an effective and sustained
response to tackling the marketing
of BMS and other non-appropriate
foods for infants and young children.
Sugar taxes
In response to rapid rises in overweight
and obesity, several countries have
applied taxes on sugary foods, with
0 4 | R E S P O N S E S TO M A L N UT R IT I O N » 13 3
sugar-sweetened beverages (SSBs) the Shirin, 16, in her grocery store in
Bangladesh. © UNICEF/UN066971/
most common target. Consumption Mawa
of such drinks is increasing in most
countries, particularly among children
and adolescents, and over-consumption
contributes to unhealthy diets and
weight gain.50 According to the Global
Nutrition Report, 59 countries have
some sort of tax on SSBs in place.51
Most recently, Malaysia, for example,
has started taxing two categories of
beverages in 2019: drinks containing
more than 5 grams of added sugar/
sweeteners per 100 ml and fruit and
vegetable juices containing more
than 12 grams of sugar per 100 ml.
Comparing sugar taxes across countries is
complicated, since they may be levied on
different products, at different levels and
for different purposes. It is too soon to
properly assess and analyse the impact
and effectiveness of this new tax.52
13 4 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
The private sector
has tremendous
potential to improve
children’s nutrition
More broadly, a recent published UNICEF
review highlights positive effects in
several countries on the consumption of
taxed products. In Mexico, for example,
consumption of taxed beverages
decreased by 5.5 per cent in 2014 and
9.7 per cent in 2015,53 while in France
the demand for colas decreased by 6.7
per cent and 6.1 per cent in the first two
years of implementation.54 The Global
Nutrition Report 2018 also reported that
some observational studies confirm that
SSB taxes are achieving positive results.55
Labelling and nutrition information
Legislation to place nutrition information
on the front of food packages is another
policy response that some countries
have used. Such labelling lets caregivers
and consumers – including children
and young people – make informed
choices and drives product reformulation.
While the evidence continues to build,
it suggests that food labelling can
help consumers overcome barriers to
meeting healthy preferences caused by
inadequate information.56 The ultimate
effect on consumers’ behaviour depends
on their existing food preferences and
level of nutrition knowledge, as well
as the type of food. When the label
is visible, easy to understand and not
misleading, it can positively affect
consumer choices. Evidence shows
that well-designed labels positively
affect all consumers regardless of
whether they’re rich or poor, and highly
educated or not.57 Nutritional labelling
can potentially create incentives for
manufacturers to reformulate their
products to make them healthier.58
There are several different approaches to
food labelling (see Spotlight ‘A pioneering
effort in food labelling’). Systems that
enable an easy, evaluative judgement
about a product’s healthiness and
wholesomeness (or otherwise) appear
particularly effective in helping caregivers
and consumers choose nutritionally
favourable products. For example, colour-
coded labels are more effective than
plain-text labels in steering consumers
toward wholesome foods.59 Among the
most common, the Multi-Traffic Light
(MTL) system is often preferred by
consumers for its ease. However, more
recent evidence finds that warning labels
and summary indicator approaches (e.g.
Nutri Score) are more strongly associated
with healthier purchases. 60 Warning
labels in particular may be a simpler and
more direct way of transmitting important
nutritional information to consumers.61, 62
There is a strong case for adopting
such labelling. Perhaps as importantly,
a recent study across Latin America
confirmed that when buying foods
for their children, parents do consider
front-of-package (FOP) information
to compare the nutritional value of
products, and they look for systems that
are easy to understand and interpret.63
Role of the private sector
The private sector has tremendous
potential to improve children’s nutrition.
Private sector actors – from smallholders
to small-and medium-sized enterprises
(SMEs), through to multinational food
corporations – all have a role to play in
transforming the world’s increasingly
complex global and local food systems.
Private sector capacity and actions along
the value chain, such as cold storage,
improved packaging, fortification and
some forms of processing, can reduce
nutrient loss, improve food safety and
deliver more nutrient-dense foods to
families.69 This is especially important
in low- and middle-income countries,
 0 4 | R E S P O N S E S TO M A L N UT R IT I O N » S P OT L I G H T » 13 5

SPOTLIGHT
A pioneering effort in food labelling

Faced with a rapid increase in overweight, which affects
almost half of its children today, Chile has launched a
comprehensive programme to try to improve children’s
food environments, with the aim of encouraging and
supporting children, young people and caregivers to make
healthier decisions.
Key initiatives include a National Food and Nutrition
Policy, which outlines the right to good-quality, culturally
appropriate food that supports good health and well-
being.64 Other actions include a new and innovative food
labelling law that aims to protect children’s nutrition
by modifying food environments, promoting informed
decisions on food, and decreasing consumption of excess
sodium, sugar and saturated fats.
The law addresses five main areas: new front of package
(FOP) warning labels; restrictions on food advertising,
especially that directed towards children aged under 14;
incorporation of messages promoting healthy lifestyle
habits in food advertising; restrictions on the sale of food
with excess sodium, sugar and saturated fats in schools;
and incorporation of activities in all schools that contribute
to developing healthy eating habits and an active lifestyle.65
The new warning labels have a striking format: white
letters on a black octagon, warning consumers that a
product is high in calories, sodium, sugar and/or saturated
fat (see below).
Evaluations of the law and its implementation indicate
that the public, especially children, support and easily
understand these new messages.66 Most consumers take
the warning labels on food products seriously and prefer
to buy foods with fewer or no labels. Also, the majority
of schools comply with the regulations, generating
healthier environments without advertising or marketing
for inappropriate foods, and the presence of healthier
food with critical nutrients, and more spaces for physical
activities.67 A number of industries have reformulated the
composition of their food products in order to stay below
the established limits of unhealthy ingredients.68 ¢

Each 100g serving contains

Calories Sugars Sat Fat Salt

Guideline Daily Amounts 353 0.9g 10.8g 1.1g

18% 1% 54% 18%

of an adult’s guideline daily amount

Each 100g serving contains

MED LOW HIGH MED

Multi-Traffic Light Calories Sugars Sat Fat Salt
353 0.9g 10.8g 1.1g
18% 1% 54% 18%

of an adult’s guideline daily amount

Traffic Light MED LOW HIGH MED

Calories Sugars Sat Fat Salt

Nutri-Score
Nutri-Score
A B C D E

ALTO EN
ALTO EN ALTO EN ALTO EN
Warning Labels AZÚCARES
GRASAS
SATURADAS SODIO CALORÍAS
Ministerio Ministerio Ministerio Ministerio
de Salud de Salud de Salud de Salud
13 6 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
The failure of the where SMEs are numerous, and sanitation
food system to and food loss are primary concerns.70
deliver healthy
food for children In many settings, large private sector
represents a players command an increasing share of
collective failure the market, giving them a tremendous
ability to either enhance or reduce the
nutritional value of foods. Processing is
key to this. The processing of food is not
inherently bad – human societies have
used it for millennia to improve the safety
and nutritional value of food and reduce
perishability. However, processing can
also remove essential nutrients and add
harmful saturated fats, trans-fats, sugar
and salt.71 As noted in Chapter 3, there
are reasons to be particularly concerned
about the rapid growth in consumption
of ultra-processed foods, which, in far
too many cases, simply fail to meet
the nutritional needs of children.
Commitments and accountability
The failure of the food system to deliver
healthy food for children represents a
collective failure. Correcting it will
require collective action by, among
others, governments, families, civil
society and the private sector. As the
role of large businesses grows in global
food systems, there is a need to ensure
they play a positive role in promoting
nutritious, safe, affordable and sustainable
foods and meet their obligations to the
world’s children and their families.
Engaging with business
Various governance mechanisms have
emphasized the need for private sector
engagement to promote better nutrition
in recent years, and for clearly defined
rules of engagement for improving
nutritional outcomes for children. As
early as 2004, the WHO World Health
Assembly endorsed the Global Strategy
on Diet, Physical Activity and Health,
which noted that the private sector can be
a significant player in promoting healthy
diets. It also highlighted the important
role of the food industry in reducing the
fat, sugar and salt content of processed
foods, reviewing marketing practices
and introducing healthier and more
nutritious choices for consumers.72
In 2015, the United Nations Secretary
General launched the Global Strategy for
Women’s, Children’s and Adolescents’
Health to strengthen the potential impact
of the SDGs. The strategy highlights the
importance of the business community
in promoting better nutrition and healthier
foods.73 The Independent Accountability
Panel created to support this strategy,
however, recommends that governments
regulate the food and beverage industry
and adopt a binding global convention
to encourage the production of healthier
foods, reduce unhealthy content and
control the marketing of unhealthy food
for children.74 Similarly, the Report of
the Commission on Ending Childhood
Obesity calls for a governance structure
in which the private sector is actively
engaged and held accountable in the
implementation of interventions.75
The food industry itself has previously
expressed a formal commitment to
working towards better diets, nutrition
and health outcomes. For example,
in May 2018, the International Food
Beverage Alliance formally expressed
commitment to align with the WHO target
to eliminate industrially produced trans-fat
from the global food supply by 2023.76
Holding food and beverage businesses
accountable to their commitments, and
monitoring their progress toward
stated goals, have proved challenging in
the past. For example, previous experience

in areas such as food marketing to
children indicates that the food industry’s
commitments are patchy, lack ambition
and are not always strictly observed.77, 78
Ensuring accountability requires strong
coordination between the public and
private sectors. Achieving better diets
for children is a shared responsibility in
which stakeholders not only recognize
their responsibility to work for better
nutrition for children, but also review
current practices that may be blocking
progress. Legislation and regulation have
an important role, but governments can
also provide incentives for businesses
to increase the demand for, and to
provide healthy food.79 Businesses
usually prefer the latter approach, and
there is evidence that such carrot-
and-stick approaches work.80
There are numerous challenges to
mobilizing action and accountability
0 4 | R E S P O N S E S TO M A L N UT R IT I O N » 13 7
from the private sector. Nutritional
goals for children and young people
compete with vested commercial
interests to create strong barriers for
significant transformation. A recent
Lancet study on obesity points out that
even though many evidence-based
actions and policy recommendations
have been identified, they have not
translated into meaningful action
due to vested commercial interests
and insufficient public demand. The
Lancet Commission has emphasized
the need to reduce the influence of
large commercial interests in policy
development, allowing governments
to implement effective policies.81
Public and private sectors have the
shared responsibility to respond and
create new avenues to deliver healthy
diets and good nutrition for children: this
response must be sustainable and drive
profound change in the current system.
A girl at Hua Ngai Primary School, in
Muong Cha, Dien Bien, Vietnam holds
up a lunch tray she has washed after
a nutritious school lunch. © UNICEF/
UN043574/Lister
13 8 U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Inge Kauer
Executive
Director,
Access to
Nutrition
Foundation
As Executive Director of the
Access to Nutrition Foundation,
Inge oversees all aspects of
ATNF, including collaboration
with external partners and
stakeholders. She is also
member of the board of ATNF.
Prior to joining ATNF, Inge was
a partner at Boer & Croon, a
Dutch-based management
consulting firm. She also
worked in senior management
positions with Porter
Novelli, a global, full-service
communications agency, and
has advised various companies
within the food and beverage
industry on socially responsible
practices and issues of
corporate reputation.
PERSPECTIVE
The food industry must accelerate action
to tackle the global nutrition crisis
What children eat and drink affects their
health and well-being in the short and
long term. Poor nutrition causes obesity
and diet-related diseases at one end of
the spectrum, and stunting, wasting and
vulnerability to infection at the other.
The global nutrition crisis is placing a
huge burden on healthcare services
and threatening the achievement of the
UN’s Sustainable Development Goals.
The private sector can make a pivotal
contribution to addressing this global
problem.
Food and beverage (F&B) manufacturers
have a huge influence on the diets of
consumers. As incomes rise, so consumers
tend to eat and drink more packaged foods
and beverages. This is driving growth in
the F&B industry, particularly in emerging
markets, where economic growth has
been almost five times faster than in
mature markets. The 22 largest F&B
manufacturers worldwide assessed in
the 2018 Global Access to Nutrition Index
operate in over 200 countries and generate
approximately US$500 billion in sales.
At the Access to Nutrition Foundation
(ATNF), we believe that these companies
have a vital role to play in addressing
the world’s nutrition challenges and the
diseases caused by poor diets. Moreover,
ATNF is convinced that companies that
adopt comprehensive global nutrition
strategies will perform better in the long
term.
The Global Access to Nutrition Index
is designed to track the contribution
being made by F&B manufacturers to
addressing global nutrition challenges and
to encourage them to do more.
We see evidence of impact: since the
2016 assessment, many companies have
stepped up their efforts to encourage
better diets, largely through better policies
and disclosure of information. Some
have also increased efforts to address
undernutrition, either philanthropically
or through their core business, by, for
example, fortifying certain foods.
While the results of the 2018 Global Index
are heartening, they also show that much
more progress still needs to be made.
The average score overall, although still
quite low, rose from 2.5 to 3.3 out of 10,
and nine companies scored 5 or more,
compared with only two in 2016. Even
so, the 2018 Index shows there is still
considerable room for improvement in the
nutritional quality of companies’ products.

The Product Profile, which assessed the healthiness
of companies’ products in nine countries, revealed
that less than one-third of the 23,000 products
surveyed can be classified as healthy.
If we zoom in on what companies are doing to
ensure good nutrition for children, the 2018 Index
raises some specific concerns. Only 14 per cent of
the products meet the WHO’s European Region
dietary guidelines for marketing to children. None of
the companies’ portfolios comprises more than 50
per cent of products that meet the healthy standard
suitable to be marketed to children. Furthermore,
most companies’ policies on responsible marketing
to children still fall short. For example, they do
not cover all media, including digital, nor apply to
children over the age of 13. Only one company
extends its policy on responsible marketing to
18-year-olds, which is considered best practice. The
2018 Index recommends companies stop on- and
offline marketing of products to children that do not
meet WHO recommendations.
The marketing of breastmilk substitutes is another
area where companies need to take action.
Companies publicly state their adherence to the
International Code of Marketing of Breast-milk
0 4 | R E S P O N S E S TO M A L N UT R IT I O N » P E R S P E C T I V E » 13 9
© UNICEF/UNI183010/Quintos
Substitutes and a few companies have strengthened
their policies in response to the 2016 Index, but
the 2018 Global Index found that all baby food
companies that we assessed continue to contravene
its guidance. Our in-depth research in Thailand
and Nigeria, for example, found a high incidence
of non-compliance with the code, mostly through
point-of-sale promotions offered by major online
retailers. Baby food companies must ensure that
their marketing policies align fully with the code, are
applied completely and consistently around the world
– in developing as well as developed countries – and
to all products, including toddler milks. Companies
can also support breastfeeding mothers in their
workplaces by offering flexible and supportive
working arrangements, stronger maternity leave
arrangements and appropriate facilities to express
and store breastmilk.
To support good nutrition for children, food
companies need to step up their efforts to market
healthy products and make more products suitable
for consumption by children. Only then can they
fulfil the enormous potential they have to contribute
to the aims of ending hunger and promoting healthy
lives that are incorporated within the Sustainable
Development Goals.¢
14 0 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Interventions to Civil society and community
promote healthy eating responses
and lifestyles
are more effective
and sustainable Local communities and civil society
when they encourage organizations (CSOs) can play a
community engagement significant role in promoting better
child nutrition, including by representing
the voices of marginalized groups
(such as smallholders, indigenous
children, and women), holding
government and business accountable,
and directly serving the nutritional
needs of their communities.82, 83
Specifically, four key roles for CSOs
were identified by The Lancet series on
Maternal and Child Nutrition (2013):
†† They can advocate nationally and
globally for nutritional priorities and
actions.
†† They can ensure accountability
for the coverage and quality of
nutrition services (similar to health
services or education services).
†† They can generate context-
specific knowledge on the causes
of malnutrition and possible
solutions.
†† They can implement nutritional
programmes and platforms for
delivery.84
One concern over the role of CSOs
is the evidence that, in some cases,
special interest groups have been
founded to set up false CSOs – a
practice called ‘astroturfing’. These
groups present the appearance of
a grassroots effort that supports
corporate agendas, for example
by challenging soda taxes.85
Top-down and bottom-up change
Community-based responses to
malnutrition are either top down or
bottom up. In a top-down response,
local groups are mobilized to implement
community-based interventions, such
as education and behaviour change
campaigns, and emergency responses.
In many cases, these interventions
are planned and designed at a national
level, but their implementation by
local groups enhances their legitimacy
and transparency. There is evidence
to suggest that interventions to
promote healthy eating and lifestyles
are more effective and sustainable
when they encourage community
engagement and consider the
specificities of the local context.86
Bottom-up responses can include
advocacy by grassroots CSOs for
systemic and fundamental change to
the food system. Among the causes
taken up by grassroots CSOs are
hunger and malnutrition, particularly in
children, soil and water conservation,
food-waste reduction, the right to food,
local food production, urban agriculture,
regulation of genetically modified
organisms, reform of trade practices,
and the rights of youth, women and
indigenous peoples. In the global south,
‘food sovereignty’ has emerged as
a key issue for grassroots CSOs. Its
core principle is that “communities
have the right to define their own
food and agriculture policy.”87
Numerous other grassroots CSOs and
social movements are working to reform
the food system and improve nutrition.
For example, the Pakistan Fisherfolk
Forum promotes the rights and
empowerment of fishing communities
and works to protect their livelihoods

SPOTLIGHT
Surviving and thriving in Peru
When they were born in 2000 in the Hanaq Chuquibamba
community, located in the Peruvian Andes, Josué Abdías
and Josué Abraham were both undernourished. Today, the
twins are healthy adolescents and both are preparing to go
to university. The twins’ turnaround mirrors Peru’s broader
success in combating undernutrition. In 2000, almost one
in three children in Peru was stunted; today, thanks in part
to interventions such as the Good Start Programme 95, from
which the twins benefited, the prevalence is just 12.9
per cent.
Peru’s success in fighting undernutrition reflects a determined
national political effort, coordination between sectors,
and an effective results-based budgeting and monitoring
system. Community leadership has also been key. In Hanaq
Chuquibamba, local leader and father of the twins, Igidio
Sataraura, emphasized the centrality of the community’s
Josué Abdías and Josué Abraham with their parents in the Hanaq Chuquibamba community in Peru. © UNICEF/ Vilca 2019
Caption
© UNICEF/X
0 4 | R E S P O N S E S TO M A L N UT R IT I O N » S P OT L I G H T » 14 1
work to monitor children’s nutritional status, ensure access
to health and nutrition services, and disseminate knowledge
about feeding and other caring practices.
However, Peru’s fight against malnutrition is not over.
There is concern over the continuing prevalence of forms
of hidden hunger, particularly iron deficiency anaemia,
and, increasingly, overweight. A stakeholder consultation
organized by UNICEF Peru in November 2018 brought
together government representatives, academia and
CSOs to reflect on strategies to continue the fight against
all forms of malnutrition. Participants recognized the new
challenges posed by persistent undernutrition and rising
overweight and emphasized the role of the public sector in
coordinating policies, strategies and programmes, as well
as the need for continued inter-sectoral coordination and
adequate funding.¢
14 2 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
through sustainable fishing policies
and practices.88 The Movimento dos
Trabalhadores Rurais Sem Terra (MST;
‘Landless Workers Movement’) is
the largest social movement in Latin
America. It has worked for over 30 years
for the principles of agrarian reform
and food sovereignty in Brazil.89 Local
CSOs are working for reform in modern
food systems in high-income countries
as well. In the UK, for example, CSOs
have been successful in promoting Fair
Trade, organic certification, ecological
approaches, permaculture, and local
and slow food movements.90
CSOs can play a key role in promoting
nutrition in non-food systems too. For
example, in the education system,
CSOs may shape policy around
obesogenic school environments,
school feeding and nutrition education.
In the social protection sector, they
may work to ensure that children from
marginalized communities receive
essential services. CSOs have also
advocated for community-led plans
for improved water and sanitation.
Despite their potential to contribute
to improving children’s nutrition,
CSOs have encountered difficulties
in participating in policy formulation
and have enjoyed relatively little
success in holding governments and
the private sector to account.91, 92
Nevertheless, there are instances of
where CSOs have been included in
national and international dialogues
to shape nutritional priorities and
policies. The SUN Movement includes
a Civil Society Network of over 2,000
local member organizations, to foster
alliances and promote nutrition actions
in SUN member countries.93 The UN
Committee on World Food Security
also has a civil society mechanism
that provides an inclusive space to
ensure civil society is represented
in wider policy debates.94
Conclusion
The evidence in this chapter is
clear: all over the world, there are
countless examples of initiatives
both big and small that are helping to
improve children’s nutrition. However,
as the continuing toll of stunting,
wasting and hidden hunger, and the
rising toll of overweight, also make
clear, much remains to be done.
If we are to meet the malnutrition
challenge full on, we need a scaled-
up approach that puts children’s
nutritional rights at the heart of food
systems and prioritizes nutrition
outcomes in other key systems. The
next, and final, chapter of this report
identifies how this can be done by
identifying five key principles to
mobilize government, business and
civil society to transform children’s
nutrition in the 21st century.¢
Mother breastfeeding her baby girl in the family yurta
in Kyrgyzstan. © UNICEF/UN0151410/Voroni
  » 14 3

Caption
© UNICEF/ ERIC TBD
14 4 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
SPECIAL SECTION
Influence of food marketing
on children’s diets
Far from being a matter of simple personal preference, individual food choices and
eating habits are largely influenced by the food environment – a mix of factors that
includes food availability, accessibility, affordability and preference. One important
influence in the food environment on consumer behaviour and a child’s diet is
food marketing.
Across high-, middle- and low-income countries,
children are becoming increasingly subjected
to ubiquitous marketing strategies that have a
powerful effect. Advertisements, food packag-
ing that attracts children and digital campaigns
all stimulate a preference for, and consumption
of unhealthy food – particularly fast food, ultra-
processed foods high in salt, sugar and/or fat, and
sugar-sweetened beverages. All these conspire to
increases the risk of overweight among children.
According to the WHO Commission on Ending
Childhood Obesity (the ECHO Commission), food
marketing is directly linked to growing overweight
and obesity and related harms to children’s health
and nutrition: “There is unequivocal evidence
that the marketing of unhealthy foods and sugar-
sweetened beverages is related to childhood
obesity.”96 For example, a survey of Australian
children aged 10–16 showed that those who en-
gaged with more food content online, especially
video ads, were more likely to consume unhealthy
food.97 Several other systematic reviews have de-
termined the extent, nature and impact of food
marketing on children and subsequent reviews
have reaffirmed these findings.98
Efforts by governments and civil society to pro-
mote healthy diets in high-income countries face a
steep challenge. The marketing of unhealthy food
outstrips spending on healthier food or healthy
food promotion in North America and Western
Europe. In 2012, the amount spent on fast-food
advertising in the United States was over 12 times
the total spent on milk, water, vegetables and fruit
combined.99 In the UK, unhealthy food advertis-
ing spending is 30 times greater than spending
by the government on healthy eating habits.100 A
recent study conducted across 22 countries found
that for every one advert for healthy foods, there
were four promoting foods high in fats, sugar and
salt – and marketing of these unhealthy products
was most frequent during children’s peak viewing
time.101 Globally, children are exposed to a huge
volume of marketing for unhealthy foods and bev-
erages, despite the implementation of self-regula-
tory initiatives by industry.
In-store marketing (retail marketing) also rep-
resents a major threat to children. A recent study
in Mexico shows that in-store techniques are
used with the specific aim of attracting children to
unhealthy foods, including, for example, the place-
ment of products at children’s eye-level, promo-
tions with prizes, and the use of licensed movie
and cartoon characters.102
Lower-income countries represent an unprec-
edented opportunity to the manufacturers and
marketers of ultra-processed foods, fast food and
sugar-sweetened beverages. From 2011 to 2016,
fast-food sales grew by 254 per cent in Argenti-
na, 113 per cent in India, 83 per cent in Viet Nam
and 64 per cent in Egypt.103 Digital marketing is
both more effective and pervasive than tradition-
al methods using TV and print, raising concerns
about the effects of food marketing. An analysis
in Europe found that combining online marketing
with other media increased the returns on TV and
cinema advertising by around 70 per cent.104 Glob-
ally, one in three internet users is estimated to be
a child. In less developed countries, the internet

Aleksa, 8, and Kosta, 12, play games on their mobile phones in Belgrade, Serbia. Digital media magnify the reach and impact of marketing unhealthy foods
to children. © UNICEF/UN040855/Bicanski
is often predominantly accessed through smart-
phones, giving food marketers a channel for adver-
tising that is available to children almost all of the
time.105
There are psychological, technical and structural rea-
sons why digital media multiplies the channels for
marketing, magnifying its reach and impact. First,
digital media allows for ‘micro-targeting’ of mar-
keting messages, reaching those most vulnerable.
Second, digital media allows for ever-evolving, novel
and creative approaches such as games, and peer
photo- and video-sharing that creates immersive, en-
gaging techniques that magnify their appeal. Third,
invasive, immersive, entertaining, high-engaging and
data-driven techniques are widely shared by children
with their peers.
In response to the growing influence of food market-
ing, in May 2010, the 63rd World Health Assembly
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unanimously endorsed the WHO recommendations
on the marketing of foods and non-alcoholic bever-
ages to children.106 WHO urges Member States to
restrict the marketing of unhealthy food to children,
to promote better nutrition, and to contribute to the
commitments to end childhood obesity. As opposed
to voluntary self-regulation by the food industry,
WHO recommends legally binding rules through
legislation.
A recent study evaluated food marketing policies and
sales in 79 countries. Assessing regulations in force
up to 2014, and food sales between 2002 and 2016,
it found that unhealthy food sales increased where
countries did not have unhealthy food marketing
regulations, whereas unhealthy food sales reduced
after such policies were implemented. Notably,
countries with industry self-regulation policies also
saw an increase in unhealthy food sales, whereas
sales decreased where regulation was statutory.107¢
14 6 U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Alejandro
Calvillo Unna
Director General,
El Poder del
Consumidor,
Mexico
Alejandro Calvillo Unna
was part of the group that
founded Greenpeace Mexico.
He worked for 12 years at
Greenpeace, with five of
those as Executive Director.
He founded the Mexican
civil society association El
Poder del Consumidor (EPC)
(‘Consumer Power’) in 2006,
where he serves as Director.
EPC has been a central
actor in obtaining a soda tax,
mandatory regulation of food
and beverages in schools,
and the implementation of a
regulation on marketing that
targets children. Alejandro
is a member of The Lancet
Commission on Obesity and
has contributed to the WHO’s
advisory groups.
PERSPECTIVE
Grassroots activism in Mexico battles
childhood obesity
An epidemic of childhood obesity is
sweeping the world. Consensus in
the scientific community and among
international organizations points to the
mass introduction of ultra-processed food
and sugar-sweetened beverages (SSBs)
into our diets as the main reason. Yet
scientific data revealing the damage to
health caused by ultra-processed foods
and recommendations by the World
Health Organization (WHO) to reduce
consumption of these products have been
vigorously contested by major multinational
food and beverage corporations.
Non-profit organizations play a vital role
in encouraging policies that take on
these powerful forces to battle the global
obesity epidemic. Academic institutions
that generate research and evidence
often do not have a prominent impact
on influencing public policy. Research
is published in scientific journals and
often remains hidden from the legislative
sphere. An alliance between academia
and civil society can unlock change, with
the latter lobbying for public policies based
on evidence generated by the former.
Non-profit organizations that fight for
public health policies to combat obesity
and regulations to create healthier
environments for children are crucial
for building discussion in the media and
generating public opinion that is favourable
to anti-obesity policies.
Public campaigns, while lacking the
vast funding that goes into advertising
junk food and SSBs, provide information
capable of generating a shift in public
awareness and a sense of urgency to act
to protect health, especially for children.
In Mexico, we created a simple campaign
in 2013 to show how much sugar there
was in a single 600-ml bottle of SSB,
the most popular container size. As of
2011, Mexico was the world’s largest
consumer of SSBs. The campaign
presented the viewer with two images.
In one ad, the caption read: “Would
you drink 12 spoonfuls of sugar? Soda
is sweet, diabetes isn’t.” In the second
ad, which showed an adult hand offering
a soft drink to a boy and a girl, the text
read: “Would you give them 12 spoonfuls
of sugar? Why do you give them soda?”
With billboards on the street and
advertising in city metro stations, the
information had a strong impact on a
population that had no idea how much
sugar these beverages contained.
The campaign, which was accompanied
by data on the growing consumption of
SSBs and the rising number of diabetes-
related deaths enabled us to present
a proposal on levying a tax on these
drinks. In 2014, we succeeded in having a
special tax of about 10 per cent imposed
on SSBs as part of Mexico’s federal
tax reform.

The demand for extra taxes on SSBs has been
accompanied by a proposal for regulations to
change the obesogenic environment for children,
such as banning unhealthy food and beverage
advertising to children and removing these products
from schools. In 2014, we successfully advocated
for legislation making school food and beverage
guidelines mandatory, although the political will
needed to enforce them has been lacking. Laws
prohibit the advertising of these products to children
on television and movies during certain hours and
require food and beverage containers to bear front-
of-pack (FOP) labels.
However, these regulations are developed by an
institution with a profound conflict of interest, and
are influenced by the interests of the food industry.
Thus, the FOP label, designed by the industry itself,
is hard for consumers to understand, and the sugar
criterion it recommends is actually a risk to health.
Regulations on advertising to children are, in practice,
a simulation: they do not cover the shows and times
that children watch the most TV, and nor do they
control advertising on the street, on the internet or
other media, or the use of gifts and promotions that
encourage children to consume unhealthy products.
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© El Poder del Consumidor, Mexico
In response, we filed multiple cases against the FOP
label. Two of these cases were ruled in our favour,
establishing that the FOP label was a violation to the
right to healthy food, information and the best interests
of the child. In parallel, the scientific community
proposed a FOP warning label for unhealthy foods
and beverages that clearly alerts the consumer if a
product is high in sugar, fats or sodium.
We also conducted a study to show that Mexican
schools remain obesogenic environments,   that the
guidelines are not enforced, and that educational
authorities must fulfil their  obligation to guarantee a
healthy environment  for children.
In some cases, such as in Chile, health authorities
and legislators committed to the common good have
pushed policies to battle the obesity epidemic without
broad-based movement from civil society. However,
in most cases, the actions of these organizations
remain crucial in driving change. The partnership
between civil society and academia requires a third
partner who is essential to achieving the common goal
– legislators and public officials who are committed to
public health and who are willing to face down the
powerful vested interests that stand in their way.¢
14 8 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

Some innovations in nutrition

NEW AND IMPROVED BETTER TASTING THERAPEUTIC FOOD
DIGITAL HEIGHT BOARDS FOR CHILDREN IN CAMBODIA

One in three children under five in Cambodia is stunted

Collecting accurate data on or underweight, but only 6 per cent of children suffering
young children’s height is from severe acute malnutrition receive treatment. To
challenging. A new digital make therapeutic food more appealing and less expensive
height board, designed than imported milk-based products, the Cambodian
for children’s c omfor t Government’s Department of Fisheries, France’s Institut de
and to yield more precise Recherche pour le Développement and UNICEF developed
measurements, is now being Nutrix. Filled with micronutrients and designed to appeal
tested. Improved estimates to Cambodian children in taste, it is locally produced and
will provide governments and made from fish, rice and beans.
practitioners with a better
understanding of the rate at
which children are growing. © UNICEF, 2019

A NEW APPROACH TO PREVENTING CHILDHOOD OBESITY THROUGH AN INNOVATIVE PARTNERSHIP

Any parent knows how difficult it can be to get children

to eat healthy food. In 2018, Beko, the leading home
appliance brand in Europe, launched #EatLikeAPro, a global
initiative to help families encourage their children to eat
better and prevent childhood obesity. Beko enlisted the
help of star players from its partner FC Barcelona to share
the stars’ favourite healthy eating stories and recipes on
the #EatLikeAPro website to inspire parents to prepare
healthier meals for their children. The campaign captured
worldwide attention, generating 28 million views with a
reach of over 140 million people.

To amplify global awareness about the importance of

healthy eating and introduce on-the-ground impact, Beko
joined forces with UNICEF, which has been working with
FC Barcelona since 2006 to promote children’s rights
and education
*Social through sport. To raise funds, Beko and
monitoring statistics
supplied by Beko.
FC Barcelona took advantage of the more than 650
million viewers of an El Clasico match and launched the
#EatLikeAPro hashtag-sharing campaign. For every hashtag
used, Beko donated 1 euro to UNICEF. The fund reached 1
million euros in 11 days, with hashtag shares taking place
in 167 countries. The funds are being used to support
UNICEF programmes in six Latin American countries to
address the root causes of the emerging overweight and
obesity epidemic.
*Social monitoring statistics supplied by Beko.
© Marc Ensenyat
In May 2019, with UNICEF’s technical input and FC Barcelona
and Barça Foundation collaboration, Beko surveyed over
13,500 children between the ages of 6 and 10 in 18 countries,
to find out whether they would eat healthier food if they knew
their hero or role model did. An overwhelming 80 per cent of
the children said they would. The consequent #EatLikeAPro
online campaign features FC Barcelona player Gerard Piqué
promoting healthy eating to primary-school children. The
campaign registered over 15 million views in its first month.*
Through this unique tripartite partnership, #EatLikeAPro
has developed into an award-winning social campaign
with global reach and importance.

USING AI-DRIVEN PHOTOGRAPHY
TO DETERMINE MALNUTRITION
The traditional approach of
measuring a child’s upper-arm
circumference and weight–
height ratio requires time,
equipment and trained staff.
Using new facial recognition
and machine learning
technologies, the Method for
Extremely Rapid Observation
of Nutritional Status assesses © Kimetrica
malnutrition in children aged 6–59 months in emergency
settings without human assessment – or error. The algorithm
estimates body mass index (BMI) by analysing a digital image
of the child. (For their safety, the actual image is not stored.)
This rapid and less intrusive tool is intended to complement
rather than replace other measurements.
A DATA-DRIVEN RESPONSE TO THE TRIPLE BURDEN IN INDIA
India’s Comprehensive National Nutrition Survey (CNNS),
which ran from 2016 to 2018 across all states, was the
biggest ever nationwide effort to paint a detailed picture of
the nutritional status of pre-schoolers, school-age children
and adolescents up to 19 years old.
For the first time, the extent and severity of micronutrient
deficiencies, information on fat distribution and nutritional
risk factors for non-communicable diseases (NCDs) and
links between children’s nutritional status and their cognitive
development were assessed in a single survey. As well as
being unprecedented in scale, the CNNS used innovative
data quality assurance measures, including SMS-based
monitoring and gold-standard methods for biological sample
collection and laboratory testing.
Notable findings from the survey, which was made possible
through a philanthropic partnership with Megha and Aditya
Mittal, included seasonal variations in vitamin A deficiency,
a large disparity in anaemia prevalence between girls and
boys, and evidence that overweight and obesity, as well
as the threat of diabetes, are on the rise among school-
age children.
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WHAT’S IN THIS?
SCAN THE BARCODE AND FIND OUT
From Australia to India to France, customers are using their
smartphones to scan barcodes on packaged foods to find
out how much sugar, salt and fat they contain. Nutritional
information collected through the FoodSwitch app for over
34,000 packaged foods was used to improve Australia’s Health
Star Rating food labelling system for sugary packaged foods.
In India, FoodSwitch was used to evaluate the healthiness of
the packaged foods sold by the largest food manufacturers.
Open Food Facts, an open-source platform that has nutritional
information on over 75,000 products, entered by volunteers
in 150 countries, was used by the French National Nutrition
and Health Programme to validate its nutrition grading scoring.
These consumer-generated databases are proving to be a
more cost-effective alternative to purchasing data from market
research companies.
© UNICEF/UN052963/Matta
These findings have informed India’s ambitious child nutrition
programmes. They also provide the basis for potential
new policy recommendations, including scaling up dietary
diversification and food fortification to address vitamin A
deficiency, tackling the triple burden of malnutrition and
starting programmes in the early years to instil healthy
lifelong eating habits.
05
AN AGENDA TO PUT
  CHILDREN’S NUTRITION
RIGHTS FIRST
 0 5 | A N AG E N DA TO P UT C H I L D R E N ’ S N UT R IT I O N R I G HT S F I RST » 15 1

One word must be at the heart of our These five key

responses are
response to children’s malnutrition – action. essential to
improve children’s
nutrition:
We need action that reflects the core role of
†† Empower families, children
food systems, that strengthens the supply of and young people to
demand nutritious food
– and demand for – better food, that improves
†† Drive food suppliers to do
children’s food environments, and that the right thing for children

†† Build healthy food

reflects the role of key supportive systems: environments for all children

health, water and sanitation, education and †† Mobilize supportive systems

to scale up nutrition
social protection. With action comes another results for all children

†† Collect, analyse and use

imperative: accountability. Progress must be good-quality data and
evidence regularly to guide
measured, shared, acted on and celebrated. action and track progress

Two girls buy guava fruits at Honiara Central Market, Guadalcanal, Solomon Islands. © UNICEF/UN0343034/Naftalin
15 2 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

Put children’s nutrition first

1 in 3 children For every child
is not growing well to grow well

1 Empower families, children and young

people to demand nutritious food
Drive food suppliers to do
the right thing for children 2
SOCIAL WATER &
PROTECTION SANITATION
18% 1%

FOOD

HEALTH EDUCATION

4 Mobilize supportive systems to scale up

nutrition results for all children
Build healthy food environments
for all children 3

5 Collect, analyse and use quality data and evidence

regularly to guide action and track progress

Introduction
Nutrition is a basic building block in a
child’s life. Every aspect of childhood
– from development in the womb, to
playing and exploring in infancy and
early childhood, and from learning in
school, to preparing for adulthood and
employment – is built on a foundation
of good nutrition. For those suffering
from malnutrition, every challenge in
life becomes more difficult and every
opportunity harder to grasp. Amid
growing concern about how the world
is feeding itself, this report proposes
an agenda for every child to eat well.
This report began by defining malnutrition
as “lack of proper nutrition, caused by not
having enough to eat, not eating enough
of the right things, or being unable to use
the food that one does eat.” Globally, one
in three children under 5 is not growing
well because of malnutrition and two in
three are at risk of malnutrition because
of the poor quality of their diets.
The nature of malnutrition is also evolving
as family diets become determined by
ever more globalized and commercialized
food systems. Food systems are failing
children and urgent transformation is
needed. Children’s unique nutritional
needs during the various stages of life
must be at the heart of the food system
transformation and a priority for all actors
involved in the provision of nutritious,
affordable, safe and sustainable diets.
This report comes at a time of concern
not only about the ability of the world
to produce enough nutritious food for
everyone, but also about its capacity to
do so sustainably in ways that protect
the planet. This report is unique in its
call to put children first, at the centre
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of the world’s food and nutrition
challenge. However, amid this wave of
interest, we would do well to remember
a proverb from Nigeria: Fine words
do not produce food. Words aren’t
enough. Our response to children’s
malnutrition must be grounded in action.
First, our response must recognize the
right of children to food and nutrition as
a human right. Thirty years ago, with
the signing of the Convention on the
Rights of the Child, world leaders came
together to commit to the right of every
child to enjoy a full childhood. Still today,
far too many children are robbed of
their present and their future because
of malnutrition. UNICEF calls on all
actors to put children first and combat
malnutrition by recommitting to the right
of all children – without exception – to
food and nutrition as a human right.
Second, women and children’s well-being
must be at the heart of government
policy. When it comes to ensuring healthy
diets, governments have a critical role
to play through policy, regulation, quality
assurance and effective programmes.
These commitments – and the financial
investments associated with them
– should be grounded in evidence
and linked to a set of clear targets
and accountability metrics for each
stakeholder. Progress towards food
and nutrition targets should be regularly
tracked, shared, acted on and celebrated.
Third, putting children at the centre of Fine words do not
food systems requires a multi-pronged produce food. Words
approach: stimulating demand for healthy aren’t enough. Our
options, strengthening the supply of response to children’s
nutritious foods, and improving children’s malnutrition must be
food environments. Experiences from grounded in action
15 4 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Dr. Pakirova prepares dinner for her
family in Kyrgyzstan’s Chon Alai district.
© UNICEF/UN0146971/Voronin
an increasing number of countries
provide examples of what works, but
better data and evidence are needed
to monitor performance, document
lessons and improve actions at scale.
Finally, our response must go beyond
the food system itself and be supported
through the efforts of other systems. We
have seen how four systems – health,
water and sanitation, education, and
social protection – can work together with
the food system to support children’s
nutrition in diverse contexts. It’s time to
enhance these interventions to scale up
the impact for nutrition. The importance
of nutrition to children’s development
and well-being, and the growth and
development of national economies and
human capital, mean that we must put
nutrition at the core of how we address
wider challenges such as in health,
education, poverty reduction and equity.
To guide the response to children’s
malnutrition, this report proposes
the following Agenda to Put
Children’s Nutrition Rights First.

1 | Empower families, children and young people to demand
   nutritious food
Demand affects supply because food
producers respond to consumer behaviours
and aspirations. When healthy options
are affordable, convenient and desirable,
parents and caregivers make better food
choices for children. As children grow
older, they make more food choices, so
knowledge and information can make them
powerful agents of change. Stimulating
demand for nutritious foods means not
only educating consumers on the benefits
of a healthy diet, but also leveraging
cultural and social aspirations to change
behaviours and practices.
†† Understand and leverage family
and community dynamics. Family
and community dynamics, including
intrahousehold distribution and the
utilization of foods, can vary greatly.
Evidence consistently shows that
when women have more education,
decision-making power and control
over the household’s income, they
tend to choose healthier foods
and feeding practices for their
children. One area of constraint is
that food preparers in households
can lack the skills to create meals
that meet the nutritional needs
of children. It is also important to
engage fathers and the extended
family to support women’s multiple
roles, especially women in the
formal and informal workforces.
†† Improve nutrition education to
enable better lifelong dietary
habits. Nutrition education starts
at home, continues in school, and
should be reinforced by public
communication campaigns. It
should also be incorporated in
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the health and social protection
systems. Parents need to be
educated about nutritious foods
and healthy feeding practices
for their children and the risks of
over-consumption of unhealthy
foods. Education should extend
beyond the benefits of healthy
foods to behaviour change and
empowerment, especially for school-
age children and adolescents, who
are themselves agents of change.
†† Improve the desirability of
healthy foods. Innovative,
fun, memorable and engaging
communication strategies to
promote healthy eating – including
but not limited to campaigns – can
leverage the social and cultural
aspirations of children, adolescents
and parents. These strategies
should capture parents’ interests
and aspirations, such as physical
growth, brain development and
school performance, as well as the
interests and aspirations of school-
age children and adolescents, such
as sport, appearance, strength, pop
culture, social media and more.
†† Use proven legislation to reduce
demand for unhealthy foods.
In certain circumstances, specific
taxes on unhealthy foods, such as
sugar-sweetened beverages, can
reduce demand for these products
by making them relatively more
expensive than healthier alternatives.
Combined with nutritional
education, these tools have proved
effective drivers towards more
nutritious diets for children. ¢
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2 | Drive food suppliers to do the right thing for children
It’s not enough that children and families
demand healthy food – it must also be
available, affordable, safe and convenient.
Food producers and suppliers have a key
role to play, and governments can set
standards to create a level playing field
for all producers and suppliers, ensuring
that their actions align with children’s best
interests. Food systems are diverse, and
so are the solutions. In non-industrialized
food systems, for example, smallholders
can be supported to raise their productivity;
in industrialized food systems, stronger
market linkages and incentive structures
can improve the availability and
affordability of fresh and healthy foods.
All food systems need to move towards
environmentally sustainable production and
consumption to protect children’s nutrition
today and in future generations.
†† Provide economic incentives,
and eliminate disincentives,
for producers to supply more
nutritious children’s foods.
Policymakers can incentivize food
producers to supply nutritious, safe
and affordable foods to children
while eliminating subsidies for sugar,
refined grains and processed oils.
As the complementary feeding
period (6–23 months) is particularly
important for children’s growth and
development, food producers should
be discouraged from marketing
nutrient-poor, sugar-rich and highly
processed foods as suitable for this
age group. Incentives should also
seek to increase the proportion
of fresh fruits and vegetables
available at markets, supermarkets
and other points of sale, especially
in low-income communities and
food deserts. Business-friendly
policies, such as reduced rents,
tariffs and utilities, can be used to
reward companies that produce
and market healthy foods.
†† Invest in the modernization of
infrastructure and transport
chains to reduce food and nutrient
losses and improve food safety,
especially in rural areas. Many of
the foods that children need most,
including fruits, vegetables, and
foods of animal origin such as fish,
eggs, milk and dairy, are also highly
perishable. Where infrastructure
is poor, much is lost to spoilage
and contamination, driving up the
price and reducing availability and
affordability. Children’s diets often
then turn to highly processed foods,
which are less expensive and have a
longer shelf-life. Investments by the
food industry and governments in
storage, packaging, processing, cold-
chain logistics and other infrastructure
to bring healthy foods to market can
reduce both the costs to producers
and the prices faced by families.
†† Strengthen policies, strategies
and programmes to enhance
the resilience of the food supply
in crisis-prone areas and fragile
contexts. In humanitarian settings,
children always suffer the most.
Appropriately formulated, ready-to-
prepare fortified complementary
foods have a critical role to play
in supporting optimal growth
and development in infants and
young children, as do ready-to-use
therapeutic foods (RUTF) for the
treatment of acute malnutrition in
children. Governments of crisis-
hit areas should ensure that such
foods are readily available through

either facilitating local production
or removing barriers to import.
Investment in well-designed social
protection programmes can ensure
that women and children living in
vulnerable households have access
to more nutritious and diverse diets.
†† Reduce the environmental
impact of food production
for today’s and tomorrow’s
children. There are clear linkages
between food production and
consumption, environmental
sustainability, and the impact on
3 | Build healthy food environments for all children
The personal and external food
environments are where children and
their caregivers interact with the food
system. While the forces of supply and
demand shape food environments,
context-appropriate actions such as
protection against exploitative marketing
and mandatory labelling can help create
food environments that are conducive to
nutritious diets for children.
†† Create environments conducive
to healthy breastfeeding
and complementary feeding
practices. Strictly enforce the
International Code of Marketing of
Breast-milk Substitutes and hold
violators accountable. Promote
supportive policies for mothers,
parents and families, including
maternity leave and the provision of
time and spaces for breastfeeding
in the workplace and in public
places. Stimulate the availability,
accessibility and affordability of
easy-to-prepare complementary
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children’s nutrition and health.
Robust interventions are needed to
reduce the environmental impact of
food production and consumption
in ways that evidence shows
are harmful to children, including
greenhouse gas emissions, fossil
fuel use, pesticide use and fertilizer
run-off. Production systems such
as agroecology, agroforestry,
intercropping and integrated
crop-livestock management can
enhance the sustainability and
biodiversity of food systems
for generations to come.¢
foods at points of sale, particularly in
low- and middle-income countries.
†† Enhance the transparency
of nutritional information
through front-of-package food
labelling. Governments should
mandate front-of-package food
labelling, especially for foods
that are marketed to children or
marketed as suitable for children.
Labelling can raise awareness
of the nutritional value of foods,
promote behaviour change among
parents, adolescents and children,
and stimulate businesses to work
towards product transformation by
adding healthier ingredients and
removing unhealthy ingredients.
To be effective, such labels need
to be prominent and instantly
readable. Quality seals and similar
highly visible certifications can
also be awarded to vendors
that provide healthy options
and food choices for children.
15 8 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
†† Regulate the marketing of
unhealthy foods to children.
Children everywhere should be
protected against the impact of
harmful and exploitative marketing
and advertising of unhealthy
foods. Regulations should target
advertising on television, and
in games, movies, books and
social media for all age groups,
as well as businesses and
restaurants that give away toys
to market unhealthy foods.
†† Reduce obesogenic influences
around places designed for
children, particularly schools.
4 | Mobilize supportive systems to scale up nutrition results
   for all children
While the food system is a critical
pillar for the provision of healthy
diets for children, four other key
systems must be mobilized to deliver
nutrition services, improve nutrition
practices and achieve nutrition
outcomes at scale. In addition to
the food system, the health, water
and sanitation, education and social
protection systems must all deliver
interventions in a coordinated fashion.
A systems approach ensures that
children and families have access to
healthy diets and receive the nutrition
services children need to grow and
develop to their full potential.
†† The health system. Actions
need to be integrated into the
health system to ensure that
children survive, grow and
For many children, schools
provide their first regularly
consumed meals outside
the home. Governments and
ministries of education need to
take steps to combat obesogenic
food environments, including
ensuring that school meals are
nutritious and diverse, limiting
the sale and advertising of sugar-
sweetened beverages and foods
high in unhealthy fats, sugar and
salt in proximity to schools and
playgrounds, and ensuring that
adequate time during the school
day is set aside for active play
in safe recreational spaces.¢
develop to their full potential.
Investment in the nutritional
knowledge and skills of health
workers, the frontline between
the health system and families, is
particularly important. Preventive
care against malnutrition, such as
early initiation of breastfeeding,
counselling and support for
exclusive breastfeeding,
complementary feeding and
maternal nutrition, are essential
services that should be delivered
during pre- and post-natal
healthcare visits. Screening and
treatment for anaemia, vitamin
A deficiency, growth failure and
excessive weight gain also require
health system skills, support
and supplies. Finally, given the
high mortality risk associated
with wasting, governments

should systematically
integrate into routine services
the early detection and
treatment of children with
life-threatening wasting.
†† The water and sanitation
system. The water and sanitation
system is critical to ensuring
children have access to safe
drinking water and safe sanitation.
Such access is essential to
ensure a healthy diet, protect
children from infection and
enteropathy to ensure their
bodies can utilize nutrients, and
to prevent stunting, wasting
and other forms of malnutrition.
Governments should support the
construction of improved latrines
and reduce the distance that
women and children must travel
to access safe drinking water
and toilets. While investments
in infrastructure are important,
behaviour change communication
for optimal feeding, safe food
handling and handwashing with
soap at critical times should be
mainstreamed in communities
and schools, targeting parents
and children from a young age.
†† The education system. The
education system can deliver a
number of nutrition interventions
to support healthy diets and
good nutrition for children and
adolescents. In both formal and
informal education settings,
nutrition education from as early
an age as possible should ensure
that children and their caregivers
are empowered to make healthy
food choices. Schools should
create healthy food environments
for children and adolescents,
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which includes ensuring the
availability of safe drinking water
and limiting the availability of
obesogenic influences within
schools and school zones. In
some contexts, school feeding
programmes may be useful in
providing nutritious meals to
vulnerable children. The education
system can play a key role in the
delivery of integrated programmes
for the prevention of iron
deficiency and anaemia through
the provision of micronutrient
supplements, deworming
prophylaxis and counselling on
healthy eating, for example.
†† The social protection system.
The social protection system
forms a crucial safety net to
protect the nutrition and well-
being of children and women from
the most vulnerable families in
society and those suffering from
social exclusion and poverty. In a
direct way, the social protection
system can ensure children’s
access to nutritious and diverse
diets through food transfers,
food vouchers or cash transfers.
Social protection programmes
can also secure access to
nutrition services through the
health system, such as pre- and
post-natal care and nutritional
counselling to mothers (including
those of malnourished children)
and through the education system
using school-feeding vouchers,
for example. In addition, the
social protection system is
essential to support children’s
and households’ food security
by preventing the depletion of
productive assets in emergencies,
such as livestock and seeds.
16 0 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
5 | Collect, analyse and use good-quality data and evidence
regularly to guide action and track progress
Accurate and timely data are required
to understand the malnutrition problem,
to take coordinated, evidence-based
action, and to hold all actors – public and
private – to account. Yet the scarcity
of data remains a major barrier that is
preventing governments from responding
with effective policies, strategies and
programmes. Data collection methods
and frequency must be transformed to
expand what we know about the diets
and nutrition of children, adolescents and
women across the lifecycle, extending
beyond the traditional focus on the first
1,000 days. Action to improve malnutrition
requires responsive data systems and a
culture of data-sharing and transparency.
†† Set targets for, and track
progress on, complementary
feeding for infants and young
children.
It is vital to address the absence of
global targets for improving the diets
of children and feeding practices
in the crucial complementary
feeding period. Global and national
targets for continued breastfeeding,
complementary feeding and healthy
diets should be set. These targets
should use standardized indicators
that can be regularly collected
in national nutrition data and
information systems and surveys.
Indicators and targets should focus
on improving positive practices, such
as increasing the consumption of
fruits and vegetables and achieving
minimum dietary diversity, as well
as reducing negative behaviours
such as the consumption of ultra-
processed foods. Tracking both
healthy and unhealthy feeding
patterns is essential to assess
how well the food system
is delivering for children.
†† Improve metrics, data collection
and targets for children’s diets and
nutrition during the school-age
years and through adolescence.
Data on older children and adolescents
are scarce and often of poor quality.
Addressing this knowledge gap
demands increased attention. Dietary
and nutritional data for school-age
children and adolescents are important
not only to understand the geographic
and socio-economic distribution of
eating patterns and different forms of
malnutrition in middle childhood and
adolescence, but also to understand
who and what influences dietary
choices – if choices do exist – in this
age group and to design effective
interventions that target school-age
children and adolescents. As is the
case with complementary feeding,
global and national targets for the
nutrition of school-age children
and adolescents are imperative
if progress is to take place.
†† Support the development
of novel analytical tools and
methodologies for studying
dynamic food systems and
identifying the factors affecting
children’s diets and nutrition.
Industrialized food systems are
characterized by complexity and
rapid change. Putting children at
the centre of food systems requires
a new set of analytical tools and
methodologies to understand
how production and consumption
 0 5 | A N AG E N DA TO P UT C H I L D R E N ’ S N UT R IT I O N R I G HT S F I RST » 16 1
choices are made, how children’s
food environments are shaped,
and how different actors and
stakeholders – public and private
– interact. A range of established
and innovative tools – including
household surveys, food mapping
and food system dashboards – can
enable policymakers to compare
their food system with those of
other similar countries and identify
key challenges and prioritize actions.
†† Set targets and improve data
collection to measure the
coverage and equity of essential
nutrition services delivered
through the health, water and
sanitation, education and social
protection systems. Globally,
much of the data in the area of
children’s nutrition relate to services
delivered through health system
interventions and contacts. Given
the important role of other systems
in supporting children’s nutrition,
improved monitoring is needed
of the interventions and actions
delivered through all programmes
and delivery platforms. Data
systems and capacities should be
strengthened to monitor newly
developed indicators and targets for
the coverage and equity of essential
nutrition interventions. This is an A child is weighed during a routine
essential step in ensuring that a growth monitoring session at the
Centre for the Protection of Mother
transparent public accountability & Child Health. Tunis, Tunisia.
system is put in place.¢ © UNICEF/UN0212543/Noorani
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SPECIAL SECTION

Better data, better diets

Like the challenge of malnutrition itself, data on child nutrition – what is tracked,
analysed and compared across geographies and populations – are evolving. The
global dietary shift and the triple burden of malnutrition are increasing the need for
more data, while technologies are opening opportunities for new understanding. As
addressing malnutrition becomes more holistic, with a focus on systems that cut
across sectors and take into account food environments and consumer behaviour,
a wider range of actionable data is needed.

Using data and evidence to shape decision-
making for policies and programming is crucial
to improving the lives of children. Unfortunately,
current data gaps, particularly on the nature and
quality of children’s diets around the world and
across the life course, make the prevalence,
nature and scope of malnutrition difficult to
understand. The broader food environment
in which dietary decisions are made is also
poorly understood, highlighting the need for
new tools to better understand children’s diets.
Methods to measure food availability, access,
affordability, demand and use as a set of inter-
related factors that influence children’s diets are
needed, along with tracking and understanding
the nutrition transition as unhealthy diets
become more prevalent worldwide.
However, the potential impact and effectiveness
of data do not lie only in tracking more indicators
or producing more surveys: the analysis and
use of existing data to drive policy advocacy
and programme design and implementation
is vital. This effort must also be linked to the
development of global and national targets for
improving children’s diets and feeding practices.
Data on children under 5
Most data on nutrition for low- and middle-
income countries relate to children under 5.
Given the influence of the first 1,000 days on
lifelong nutrition, health and economics and
the amount of programming on early childhood
nutrition globally, this isn’t surprising. Indicators
for this age group include:
†† prevalence of low birthweight, stunting, wast-
ing, and overweight
†† rates of early, exclusive and continued breast-
feeding
†† timely introduction of complementary foods
†† minimum meal frequency
†† minimum diet diversity and minimum accept-
able diet for ages 6–23 months
†† vitamin A supplementation coverage, among
others.
In low- and middle-income countries, stunting
and overweight among children under 5 are
tracked closely at the national level, albeit with
varying frequency. Some countries invest in
annual data collection, while others collect data
every three to five years. Wasting, on the other
hand, is a condition that can change seasonally
and rapidly, so trends over time can be difficult
to identify, although snapshot data are tracked
through Multiple Indicator Cluster Surveys (MICS)
and Demographic and Health Surveys (DHS),
among others. With current data, countries and
regions can be compared, but sub-national data
by household wealth and geographic and sex
differentials, available in some countries, can
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reveal important disparities that inform policy and
local implementation. In high-income countries,
on the other hand, these nutrition indicators tend
to be lacking for children under 5 since they are
either not collected systematically or not routinely
reported in a comparable way.
Data gaps on the nutritional status of
school-age and adolescent children
The nutritional status of older children is less
well understood and tracked. The WHO/CDC
Global School-Based Student Health Survey asks
adolescents aged 13–17 about some aspects
of their dietary behaviour (consumption of
fruits, vegetables, soft drinks and fast food) and
physical activity (physical education and cycling/
walking to school), and indicators on overweight
and thinness are tracked. However, these data
are based on self-reported height and weight in
European countries, which could underestimate
obesity rates because of social desirability bias.1
Additionally, the overarching gap is that a child’s
nutritional well-being throughout the life course
is not tracked systematically. There is currently
no standardized set of recommended indicators
to be collected routinely through administrative
systems, and no surveys at the country level.
Dietary habits and food intake
Another major gap is the lack of whole-of-diet
data on what children, adolescents and women
actually eat, and a dearth of data on micronutrient
malnutrition. Without more knowledge on
patterns and distributions of dietary habits, it is
difficult to establish dietary priorities and goals.
Feeding practices for young children and mothers
are tracked through household surveys, with
the indicators for minimum dietary diversity
(percentage of children 6–23 months of age who
received foods from five or more food groups
the previous day) and minimum acceptable diet
(number of children aged 6–23 months of age
who had at least the minimum dietary diversity
and meal frequency the previous day).
However, including diet diversity indicators –
tracking how much and how often foods of various
kinds are consumed, weighted by nutritional
value – in more surveys for a broader range of
children would provide a better understanding of
malnutrition. These indicators have been found to
be powerful predictors of economic status and
malnutrition (both stunting and wasting).
Gathering reliable information on what children,
adolescents and women eat is fraught with
challenges. One example in data collection among
school-age children is their limited cognitive
ability to self-report their food intake. Some
questionnaires can also be quite long, straining
children’s shorter attention spans. Many studies
rely on questionnaires completed at school by
children with little involvement of their parents.
School-age children have been known to under-
report or over-report their dietary intake, limiting
the reliability of some data.
Surveys of adolescents are hampered by their
lack of motivation to respond to voluntary
questionnaires and body image issues. Under-
reporting and misreporting of food intake
are common among overweight and obese
adolescents.
Finally, food composition databases, which give
(not always accurate) estimates for energy and
macro- and micronutrient levels in common
local foods, are either unavailable at the country
level or not uniform across countries, making
cross-country comparisons difficult. They do not
adequately address the special needs of young
children. In many studies, global food composition
databases are modified to accommodate country-
specific foods, again making comparisons
unreliable.¢
16 4 U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019

PERSPECTIVE
Working together to deliver healthy people
and a healthy planet

Peter Bakker It is painfully visible that our food system is which all have a direct impact on the bottom
President and broken. Our future depends on our ability to line. As populations grow and diets evolve,
CEO, create a food system that supports healthy there are growth opportunities for compa-
World Business people and a healthy planet. Current food nies that move first and create new markets
systems are outstripping the resources of for healthy food.
Council for
the planet, while diets are resulting in global
Sustainable
health crises of both over- and undernutrition. Food companies can help nudge parents
Development All this will be amplified by continued popu- and children towards healthy and sustainable
lation growth and changes in dietary habits. food options. For example, advertising and
in-store marketing are powerful tools that af-
The private sector is often seen as part of the fect consumer behaviour. At the same time,
problem, but I believe it can play a pivotal role business also needs to show restraint in
in providing solutions. Take food processing advertising directly to children, because they
for example: it can deliver high-quality food are particularly susceptible to commercial
that extends the life of fruit and vegetables, messages. At the World Business Council
thus reducing food waste. It can make for Sustainable Development (WBCSD), we
healthy foods available all year round in en- are helping businesses to accomplish this,
Peter Bakker is President vironmentally challenged communities such for example by developing a country-level
and Chief Executive as the Sahel region. In addition, when food project that includes a toolkit on marketing
Officer (CEO) of
the World Business
is produced responsibly, the environmental and advertising products containing less
Council for Sustainable impact of agricultural practices can be kept sugar.
Development (WBCSD), to a minimum or even be regenerative.
a global, CEO-led
Public education campaigns play an impor-
organization of over
200 leading businesses Nearly all food consumed around the world is tant role as well. A combination of policy,
working together to produced, processed or supplied by business, information and community engagement is
accelerate the transition
ranging from smallholder farmers and family required to reach everyone, including those
to a sustainable world.
WBCSD member farms to large, multinational companies. This living in disadvantaged communities.
companies come from provides business with a unique opportunity
all business sectors and and ability to improve children’s health and We must also focus more on the environmen-
all major economies,
representing a combined
quality of life by creating more healthy, enjoy- tal impact of food production. As we move
revenue of more than able food for all, that is produced responsibly towards the limits of the natural resources
US$8.5 trillion and with and sustainably. our planet can provide, diets need to be
19 million employees. Mr
adjusted. Initiatives such as the EAT-Lancet
Bakker is a distinguished
business leader who, There is a clear business imperative to help Commission report, the FABLE Consorti-
until June 2011, served meet the nutritional needs of children: mal- um’s national country modelling, the Food
as Chief Finance Officer
nutrition contributes to reduced productivity, Systems Dialogues, and the Food and Land
and then CEO of TNT
NV, the global transport and rising health, insurance and environmen- Use Coalition are at the forefront of solving
and logistics company. tal costs, as well as vulnerable supply chains, this challenge. Many leading businesses
 0 5 | A N AG E N DA TO P UT C H I L D R E N ’ S N UT R IT I O N R I G HT S F I RST » P E R S P E C T I V E » 16 5
support and encourage their evidence-based work,
using it to inform business strategy and actions.
Finally, healthy and sustainable food must be
accessible and affordable. We cannot reinforce
socio-economic inequities in feeding our children.
Unfortunately, even in areas where food is widely
available, healthier and more sustainable options are
often more expensive. Moreover, many smallholder
farmers don’t have sufficient food remaining from
their harvest, or enough money to purchase diverse
healthy foods.
From a business perspective, today’s children are
tomorrow’s farmers and company workers. Failing
them is not an option, yet we are on a path to do so.
We need to react urgently, and business must make
bold strides to contribute to finding solutions.
At WBCSD, we’re bringing together companies that
are taking a leadership role to explore, develop and
scale up solutions. Many of our member companies,
individually and through WBCSD programmes and
projects, are innovating to shift towards healthy diets
Our organization calls on business to transform the
food system to achieve a vision of healthy people
and a healthy planet, by:
© UNICEF/UN016877/Noorani
†† ensuring food and nutrition security in the supply
chain
†† making healthy, nutritionally appropriate and
sustainably produced foods accessible and af-
fordable to children and their families
†† using the power of marketing responsibly by
rebalancing marketing spending on healthy offer-
ings, providing actionable information and making
healthy options easily accessible
†† engaging in platforms that convene business,
government, science and civil society to trans-
form the food system.
There is no silver bullet to solve malnutrition and only
a collaborative and holistic approach will successfully
transform the food system.
There is a massive urgency to act NOW: we have
to build momentum for our children and our planet.
Research published by the EAT-Lancet Commission
has provided targets against which we can take
aligned action. Let’s work together to transform
the food system and achieve our vision for healthy
people and a healthy planet. ¢
16 6 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 019
Endnotes
INTRODUCTION: GROWING WELL IN A CHANGING WORLD
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2 NCD Risk Factor Collaboration (2017). ‘Worldwide
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and obesity from 1975 to 2016: A pooled analysis of
2416 population-based measurement studies in 128.9
million children, adolescents, and adults’, The Lancet,
390(10113), pp. 2627–2642.
3 Ashkan, A., et al. (2017). ‘Health effects of dietary risks
in 195 countries, 1990–2017: A systematic analysis for
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393(10184), pp. 1958–1972.
4 ibid.
5 Keats, E. C., et al (2018). Diet and eating practices
among adolescent girls in low- and middle-income
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6 FAO, IFAD, UNICEF, WFP and WHO (2019). The State
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6 Blencowe, H. el al. (2019). ‘National, regional, and
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7 de Onis, M. and Branca,F. (2016). ‘Childhood stunting:
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8 Walker, C. L. F., et al. (2013). ‘Global burden of
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9 Smith, L. C. and Haddad, L. (2015). ‘Reducing child
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8 Ashkan, A., et al. (2017). ‘Health effects of dietary risks
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9 Pries, A.M., et al (2019). ‘Unhealthy snack food and
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10 Willett, W., et al. (2019). ‘Food in the Anthropocene:
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11 Searchinger, T., et al (2018). World Resources Report:
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11 UNICEF, WHO and World Bank (2019). Joint child
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12 Black, R. E., et al. (2013). ‘Maternal and child
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15 Myatt, M., et al. (2018). ‘Children who are both wasted
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17 Olofin, I., et al. for the Nutrition Impact Model Study
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13 HLPE (2017). Nutrition and food systems. A report by
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14 Hossain, N. (2017). ‘Inequality, hunger and malnutrition:
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15 ILO (2017). Global estimates of child labour: Results and
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18 USAid (2016). ‘Community-based management
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22 Jesson, J., et al. (2015). ‘Prevalence of malnutrition
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23 Muenchhoff, M., et al. (2018). ‘Malnutrition in HIV-
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28 Bhutta, Z. A., et. al. (2013). ‘Evidence-based
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29 Gillespie, S., et al (eds) (2016). Nourishing Millions:
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30 Daru, J., et al. (2018). ‘Risk of maternal mortality
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31 UNICEF (2018). ‘Globally, 86 per cent of the
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32 UNICEF estimates, 2019 based on Black et al, 2013
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33 UNICEF (2004). ‘The hidden hunger of the vitamin
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34 Kennedy, G. Ballard, T. and Dop, M. (2013). Guidelines
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37 Swinburn, B. A., et al. (2019). ‘The Global
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38 UNICEF estimates, 2019 based on Black et al, 2013
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39 Bird, J. K., et al. (2017). ‘Risk of deficiency in
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44 ibid.
45 Ng, M., et al. (2014). ‘Global, regional, and national
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47 Manios, Y., et al. (2018). ‘Prevalence and
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48 Spinelli, A., et al. (2019). ‘Prevalence of severe
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49 Ng, M., et al. (2014). ‘Global, regional, and national
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50 Manios, Y., et al. (2018). ‘Prevalence and
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study’, Nutrition, 55–56, pp. 192–198.
51 NCD Risk Factor Collaboration (2017). ‘Worldwide
trends in body-mass index, underweight,
overweight, and obesity from 1975 to 2016:
A pooled analysis of 2416 population-based
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52 ibid.
53 Department of Health and Human Services
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55 ibid.
56 Kraak, V.I., at al. (2016). ‘Progress achieved in
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57 Development Initiatives (2017). Global Nutrition
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58 Hruby, A. and Hu, F. B. (2015). ‘The epidemiology of
obesity: A big picture’, Pharmacoeconomics, 33(7),
pp. 673–689.
59 NCD Risk Factor Collaboration (2017). ‘Worldwide
trends in body-mass index, underweight,
overweight, and obesity from 1975 to 2016:
A pooled analysis of 2416 population-based
measurement studies in 128·9 million children,
adolescents, and adults’, The Lancet, 390(10113),
pp. 2627–2642, p. 2640.
60 OECD (2017). Obesity Update 2017, The
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61 ibid.
62 WHO (2016). Report of the Commission on Ending
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63 Development Initiatives (2017). Global Nutrition
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64 ibid., p. 62.
65 Wasting–Stunting Technical Interest Group
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66 McDonald, C. M., et al. (2013). ‘The effect of
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Meta-analysis of individual data in 10 prospective
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67 Khara, T. and Dolan, C. (2014). Technical Briefing
Paper: Associations between Wasting and Stunting,
policy, programming and research implications.
Emergency Nutrition Network, Oxford, UK.
68 Harding, K. L., Aguayo, V. M. and Webb, P. (2018).
‘Factors associated with wasting among children
under five years old in South Asia: Implications for
action’, PLoS ONE 13(7), e0198749.
69 Development Initiatives (2018). 2018 Global
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70 De Lucia Rolfe, E., et al. (2018). ‘Associations of
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71 Dang, A. and Meenakshi, J. V. (2017). ‘The
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72 Aitsi-Selmi, A. (2014). ‘Households with a stunted
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73 Horta, B. L., et al. (2013). ‘Nutritional status
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74 UNICEF, WHO and World Bank (2019). Joint child
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75 Popkin, B. M., Adair and Ng, S. W. (2012). ‘Global
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76 Hawkes, C., Harris, J. and Gillespie, S. (2017).
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77 FAO (2013). The State of Food and Agriculture: Food
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78 Global Panel on Agriculture and Food Systems
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79 HLPE (2017). Nutrition and food systems. High Level
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80 This section draws on UNICEF, GAIN (2018). ‘Food
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81 UNICEF, GAIN (2019). ‘Food systems for children
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82 Pinstrup-Andersen, P. (2013). Nutrition-sensitive
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83 Jones, A. D. and Ejeta, G. (2015). ‘A new global
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84 Gillespie, S. and van den Bold, M. (2017).
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85 FAO (2013). The State of Food and Agriculture: Food
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86 Ruel, M. T. and Alderman, H. (2013). ‘Nutrition-
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87 Herforth, A. and Harris, J. (2014). ‘Understanding
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88 Ruel, M. T. and Alderman, H. (2013). ‘Nutrition-
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89 Gillespie, S. and van den Bold, M. (2017).
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90 WHO Regional Office for Europe (2018). Evaluating
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91 Grassi, F., Landberg, J. and Huyer, S. (2015). Running
out of time: The reduction of women’s work burden
in agriculture production. Food and Agriculture
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92 Rasella, D., et al. (2013). ‘Effect of a conditional
cash transfer programme on childhood mortality:
A nationwide analysis of Brazilian municipalities’,
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93 Grassi, F., Landberg, J. and Huyer, S. (2015).
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94 UNICEF (2018). Generation 2030: Africa 2.0. UNICEF,
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17 Chowdhury, R., Sinha, B., Sankar, M. J., Taneja, S.,
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Pediatría, 89(5),pp. 579–581.
66 Correa, T., Fierro, C., Reyes, M., Dillman Carpentier,
F. R., Taillie, L. S. and Corvalán, C. (2019). ‘Responses
to the Chilean law of food labeling and advertising:
Exploring knowledge, perceptions and behaviors of
mothers of young children’, International Journal of
Behavioral Nutrition and Physical Activity 16(1), p.21.
67 ibid.
68 Kanter, R., Reyes, M., Swinburn, B., Vandevijvere, S.
and Corvalán, C. (2019). ‘The food supply prior to the
implementation of the Chilean law of food labeling
and advertising’, Nutrients 11(1), p. 52.
69 Downs, S. and Fanzo, J. (2016). ‘Managing value
chains for improved nutrition’. In M. Eggersdorfer,
K. Kraemer, J. B. Cordaro, J. Fanzo, M. Gibney, E.
Kennedy, A. Labrique and J. Steffen. Good nutrition:
perspectives for the 21st century, pp. 45–59. Krager
Publications, Basel.
70 FAO (2013). The State of Food and Agriculture
2013: Food Systems for Better Nutrition. Food and
Agriculture Organization, Rome.
71 HLPE (2017). Nutrition and food systems. A report by
the High-Level Panel of Experts on Food Security and
Nutrition of the Committee on World Food Security,
Committee World Food Security, Rome.
72 WHO (2004). Global Strategy on Diet, Physical
Activity and Health. WHO, Geneva, p.13.
73 United Nations (2016). The Global Strategy for
Women’s, Children’s and Adolescents’ Health
(2016–2030). United Nations, New York.
74 Independent Accountability Panel for Every Woman,
Every Child, Every Adolescent (IAP) (2018). Private
Sector: Who is Accountable? Summary Report.
WHO, Geneva, p.5.
75 WHO (2017). Report of the Commission on Ending
Childhood Obesity. Implementation plan: Executive
summary. WHO, Geneva, p. 9.
76 International Food and Beverage Alliance (2019).
Enhanced commitment to phase out industrially
produced trans-fatty acids, Press Release
(undated). <https://ifballiance.org/uploads/
press/pdf/5ccc4b8061475_IFBA%20iTFA%20
Enhanced%20Commitment%2002.05.2019.pdf>
retrieved 26 July 2019.
77 WHO Regional Office for Europe (2018).
Evaluating Implementation of the WHO Set of
Recommendations on the Marketing of Foods and
Non-Alcoholic Beverages to Children. WHO, Geneva.
78 Kelly, B., Vandevijvere, S., Ng, S., Adams, J.,
Allemandi, L., Bahena-Espina, L., Barquera, S., et al.
(2019). ‘Global benchmarking of children’s exposure
to television advertising of unhealthy foods and
beverages across 22 countries’, Obesity Reviews,
https://doi.org/10.1111/obr.12840.
79 Haddad, L. (2018). ‘Reward food companies for
improving nutrition’, Nature, 556(7699),pp.19–22.
80 Afshin, A., Peñalvo, J. L., Del Gobbo, L., Silva, J.,
Michaelson, M., O’Flaherty, M. et al. (2017). ‘The
prospective impact of food pricing on improving
dietary consumption: A systematic review and meta-
analysis’, PloS One, 12(3), e0172277.
81 Swinburn, B. A., Kraak, V.I., Allender, A., Atkins,
V.J., Baker, P. I., Bogard, J. R., Brinsden, H., Calvillo,
A., De Schutter, O., Devarajan, R., Ezzati, M., Friel,
S., Goenka, S., Hammond, R. A., Hastings, G.,
Hawkes, C. et al. (2019). ‘The global syndemic of
obesity, undernutrition, and climate change: The
Lancet Commission report’, The Lancet, 393(10173),
pp.791–846.
82 HLPE (2017). Nutrition and food systems. A report by
the High-Level Panel of Experts on Food Security and
Nutrition of the Committee on World Food Security,
Committee World Food Security, Rome.
83 Swinburn, B., Kraak, V., Rutter, H., Vandevijvere, S.,
Lobstein, T., Sacks, G. et al. (2015). ‘Strengthening
of accountability systems to create healthy food
environments and reduce global obesity’, The Lancet,
385(9986), pp.2534–2545.
84 Gillespie, S., Haddad, L., Mannar, V., Menon, P.

and Nisbett, N. (2013). ‘The politics of reducing
malnutrition: Building commitment and accelerating
progress’, The Lancet, 382(9891), pp. 552–569.
85 Yanamadala, S. Bragg, M. A., Roberto, C. A. and
Brownell K. A. (2012). ‘Food industry front groups
and conflicts of interest: the case of Americans
Against Food Taxes’, Public Health Nutrition, 15(8).
pp. 1331–1332.
86 King, L., Gill, T., Allender, S. and Swinburn, B. (2011).
‘Best practice principles for community-based
obesity prevention: Development, content and
application’, Obesity Reviews, 12(5), pp. 329–338.
87 Patel, R. C. (2012). ‘Food sovereignty: Power, gender,
and the right to food’, PLoS Medicine, 9(6), e1001223.
88 Pakistan Fisher Folk Forum <http://pff.org.pk/>
89 Movimento dos Trabalhadores Rurais Sem Terra
(MST) <https://www.mstbrazil.org/content/what-
mst>
90 Durrant, R. (2014). Civil society roles in transition:
towards sustainable food? Briefing Paper. Food
Research Collaboration, Centre for Food Policy, City,
University of London.
91 Swinburn, B., Kraak, V., Rutter, H., Vandevijvere, S.,
Lobstein, T., Sacks, G. et al. (2015). ‘Strengthening
of accountability systems to create healthy food
environments and reduce global obesity’, The Lancet,
385(9986), pp.2534–2545.
92 HLPE (2017). Nutrition and food systems. A report by
the High Level Panel of Experts on Food Security and
Nutrition of the Committee on World Food Security.
Rome.
93 SUN Civil Society Network <https://
CHAPTER 5: AN AGENDA TO PUT CHILDREN’S NUTRITION RIGHTS FIRST
1 Elgar, F. J. and Stewart, J. M. (2008). ‘Validity of
self-report screening for overweight and obesity:
Evidence from the Canadian Community Health
Survey’, Canadian Journal of Public Health, 99(5),
METHODOLOGIES FOR THE STATE OF THE WORLD’S CHILDREN 2019 WORKSHOPS
1 US Department of Agriculture and US Department of
Health and Human Services (2015). Dietary guidelines
for Americans 2015–2020, 8th ed. US Government
Printing Office, Washington DC.
NOTE ON FIGURES
1 Black, R.E., et al., Maternal and child undernutrition
and overweight in low-income and middle-income
countries. The Lancet, 2013. 382(9890): p. 427-51.
2 WHO, Iron deficiency anemia. Assessment, Prevention
and Control. A guide for programme managers. WHO
(Geneva): 2001.
3 Williams, A.M., et al., Data needed to respond
appropriately to anemia when it is a public health
problem. Ann N Y Acad Sci, 2019. 1450(1): p. 268-280.
scalingupnutrition.org/sun-supporters/sun-civil-
society-network/>
94 Civil Society and Indigenous Peoples’ Mechanism
for relations with the UN Committee on World Food
Security <http://www.csm4cfs.org/the-csm/>
95 Launched by the Ministry of Health and UNICEF
with support from USAID in 1999, the programme
promoted growth and development for young
children (from conception to 3 years of age) in rural
communities in Andean and Amazon regions. The
programme promoted health, nutrition, caring and
hygiene practices with an emphasis on local and
community involvement.
96 World Health Assembly (2016). ‘Report of the
Commission on Ending Childhood Obesity’,
Resolution A69/8, 24 March 2016, WHO, Geneva, p.
19.
97 Baldwin, H. L., Freeman, B. and Kelly, B. (2018).
‘Like and share: Associations between social media
engagement and dietary choices in children’, Public
Health Nutrition 21(17), pp. 3210–3215.
98 For summaries of existing evidence, see Cairns,
G., Angus, K., Hastings, G. and Caraher, M. (2013).
‘Systematic reviews of the evidence on the nature,
extent and effects of food marketing to children: A
retrospective summary’, Appetite 62, pp. 209–215;
Boyland, E. and Tatlow Golden, M. (2017). ‘Exposure,
power and impact of food marketing on children:
Evidence supports strong restrictions’, European
Journal of Risk Regulation 8(2), pp. 224–236.
99 Harris, J. L., Schwartz, M. B., Munsell, C. R. et al.
(2015). Fast Food Facts 2013: Measuring progress in
nutrition and marketing to children and teens. UConn
pp. 423–427; Stommel, M. and Schoenborn,
C. A. (2009). ‘Accuracy and usefulness of BMI
measures based on self-reported weight and
height: Findings from the NHANES & NHIS
2 Australian National Health Medical Research Council
(2013). Eat for health: Australian dietary guidelines.
Australian Government, National Health and Medical
Research Council and Department of Health and
Ageing.
4 Stevens, G.A., et al., Trends and mortality effects of
vitamin A deficiency in children in 138 low-income
and middle-income countries between 1991 and 2013:
a pooled analysis of population-based surveys. The
Lancet Global Health, 2015. 3: p. e528–36.
5 United Nations, Department of Economic and Social
Affairs, Population Division (2019). World Population
Prospects 2019, Online Edition. Rev. 1.
E N D N OT E S » 17 7
Rudd Center for Food Policy and Obesity, Hartford,
CT.
100 O’Dowd, A. (2017). ‘Spending on junk food
advertising is nearly 30 times what government
spends on promoting healthy eating’, BMJ, 359,
j4677.
101 Kelly, B., Vandevijvere, S., Ng, S., Adams, J.,
Allemandi, L., Bahena-Espina, L., Barquera, S., et al.
(2019). ‘Global benchmarking of children’s exposure
to television advertising of unhealthy foods and
beverages across 22 countries’, Obesity Reviews,
<https://doi.org/10.1111/obr.12840>.
102 UNICEF Regional Office for Latin America and the
Caribbean, ‘Childhood Overweight and the Retail
Environment in Latin America and the Caribbean:
Synthesis report’, United Nations Children’s Fund,
Panama City, September 2019.
103 Euromonitor International data, cited in D. Searcey
and M. Richtel (2017). ‘When KFC Came to Ghana’,
New York Times, 2 October, p. A1.
104 WHO (2016). Tackling food marketing to children in a
digital world: Trans-disciplinary perspectives. WHO,
Geneva.
105 UNICEF (2017). The State of the World’s Children
Report. Children in a Digital World. UNICEF, New
York.
106 World Health Assembly Resolution 63.14: Marketing
of foods and non-alcoholic beverages to children.
107 Kovic, Y., Noel, J. K., Ungemack, J. A. and Burleson,
J. A. (2018). ‘The impact of junk food marketing
regulations on food sales: An ecological study’,
Obesity Reviews, 19(6), pp. 761–769.
2001–2006’, BMC Public Health, 9, p. 421.
3 Krasevec, J., An, X., Kumapley, R., Bégin, F. and
Frongillo, E. A. (2017). ‘Diet quality and risk of stunting
among infants and young children in low-and middle-
income countries’, Maternal & Child Nutrition, 13
(Supplement 2), e12430.
17 8 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
Methodologies for The State of the World’s
Children 2019 workshops
Methodology
The State of the World’s Children
2019 workshops used a distributed
data-gathering process to collect
adolescents’ and mothers’ insights,
perceptions and experiences of
food and nutrition. This process was
co-designed by a team at Western
Sydney University (WSU) and UNICEF
and has been used previously in a
range of international, child-centered
research and child consultation
projects, including for The State of
the World’s Children 2017 report.
The process engaged representatives
from UNICEF country offices and
national committees to deliver five-
hour, face-to-face workshops with
adolescents aged between 14 and
16 (although a number of participants
were older or younger than this), and
with mothers of babies and infants who
were still receiving complementary
feeding. The workshops used a range
of creative activities to elicit responses
from participants. These focused on
themes identified by UNICEF, WSU
and an advisory board (see Table A1).
Before organizing the workshops,
facilitators received a detailed guide
and participated in a 90-minute
training webinar to learn about
workshop recruitment, content
and administrative processes.
By the end of July 2019, workshops had
been held in 18 countries: Afghanistan,
Australia, Bangladesh, China, Egypt,
Ethiopia, Ghana, Guatemala, India,
Indonesia, Kyrgyzstan, Mexico, Nigeria,
the Philippines, Serbia, the Sudan,
the United States and Zimbabwe.
With one exception, each country
hosted four workshops, and in total,
48 workshops were hosted for 464
adolescents and 328 mothers (five
countries are missing from this
analysis). The average workshop size
was 16.5 participants. Participating
country offices and national
committees recruited a diverse
sample of participants, and some
also ran workshops with specific
groups, for example, internally
displaced refugees in the Sudan.
The research received ethics
approval from Western Sydney
University’s Human Research Ethics
Committee (Approval No. H11101).
Support for the project was provided
by the Government of Norway.
Data collection and analysis
Data and analysis from the
workshops are not statistically
representative. Rather, the aim
was to enable adolescents and
new mothers to describe in their
own words their perceptions and
experiences of the foods they eat
and their ideas about nutrition.
The bulk of the data collected was
qualitative. Participants worked
individually and in groups to
complete surveys, short-answer
questions, creative exercises (e.g.,
drawing), scenario-based exercises
and small-group discussions. The
data gathered consisted of paper-
based surveys, diagrams, drawings,
written text and photographs.
Research materials were supplied
in English. Where required, the
staff of country offices translated
materials into local languages
before administering workshops.
All non-English content generated
by participants was translated into
English by the staff of participating
offices. Analysts had access to both
the translated and original versions.
All the data were digitized by
participating offices and uploaded
to secure digital repositories. The
data were then collated and analysed
by the WSU team, both manually
and using analysis software.
Thematic analysis was applied
as the primary technique for
understanding the data.
During data entry, individual
researchers categorized relevant data
blocks (e.g., phrases, quotes and
sentences) according to the existing
themes, and also derived new themes
generated by the data. The team then
reviewed and discussed relevant data
and individual analyses, checking
and refining their interpretations.
Analyses were summarized and
presented using quotes and images
from participants, synopses (i.e., core
insights and ideas derived from the
data), and charts and graphics depicting
key concepts and general trends.
Companion reports containing more
extensive results and analysis from the
workshops will be published in 2020.
Dietary coding
The evidence-based dietary guidelines
of the governments of the United
States and Australia respectively
were used to code the data.1, 2 These
guidelines provide a grouping of
foods that are recommended for
daily consumption (core foods) for
nutritional adequacy and growth,
and additional food groups identified
as being suitable for occasional
consumption (non-core foods) to
prevent diet-related chronic diseases.
A point of difference from these
dietary guidelines in our coding is
the separation of animal-based and
plant-based protein. This separation
was to specifically explore where
and when participants did or did
not have access to animal-based
protein. With an association shown
between children who do not consume
adequate amounts of egg, meat and
dairy and higher risks of stunting,
the identification of this distinction
in protein sources is important.3
 M E T H O D O L O G I E S F O R T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 01 9 WO R K S H O P S » 17 9

Workshop themes
Adolescents Mothers
Diet and nutritional intake Children’s dietary intake
Health and body imagew Mothers’ dietary intake
Food marketing Influences on mothers’ feeding decisions
Food influences and environments: school Feeding outside the home
Food influences and environments: home Information sources for feeding
Barriers to healthy eating Barriers faced by mothers feeding their babies
Food culture and special occasions Feeding toddlers
Food sourcing and preparation Sourcing and preparing family meals

Core Foods
Grains (e.g. breads, breakfast cereals, grains, noodles, pasta)
Animal protein (e.g. lean meats, lean poultry, fish, seafood, eggs)
Plant protein (e.g. nuts, seeds, legumes, beans, tofu)
Dairy (e.g. milks, yoghurt, cheese)
Vegetables (e.g. dark green or cruciferous, root, tubular and bulb vegetables, legumes, beans)
Fruits (e.g. citrus, pome, tropical, berries, stone, figs, grapes, lychees)
Unsaturated fats (polyunsaturated fats, mono-unsaturated fats)
Non-core Foods
Higher added sugars (e.g. honey, jams, marmalade, sugar, sugar confectionary, syrups)
Higher saturated fat and sodium (e.g. bacon, cream, commercially fried foods, commercial burgers)
Higher saturated fat and added sugars/sodium (e.g. biscuits, cakes, chocolate)
Drinks
Soft drinks Fruit juices, cordials
Caffeine Water
Alcoholic drinks Energy drinks

Note on figures
Figure A.1: Children not growing well
Children not growing well represents
the percentage of children in one
of the five categories: stunted,
wasted, overweight, stunted and
overweight, or stunted and wasted;
the first three categories are often
available in survey reports, but the
last two categories require analysis
of microdata. Estimates are based
on 441 data sources included in the
2019 edition of the Joint Malnutrition
Estimates (JME) where microdata was
available for analysis. For countries
without microdata, regional adjustment
factors were applied based on the
sub-regional aggregates of the overlap
of stunting and wasting and stunting
and overweight to generate country
estimates of the five categories.
Global and regional aggregates are
based on the methodology described
in de Onis M, Blössner M, Borghi
E, Frongillo EA, Morris R. Estimates
of global prevalence of childhood
underweight in 1990 and 2015.
JAMA. 2004 Jun 2;291(21):2600-
6. PubMed PMID: 15173151.
Figure 1.4: Hidden hunger
The prevalence of hidden hunger
is based on estimates of iron and
vitamin A deficiency among children
under-5 years, by UN sub-region.
Prevalence of iron deficiency anemia
(IDA) is based on Black et al. (2013).1
A conversion factor of 2.02, 3 was
applied to calculate the prevalence of
iron deficiency. Prevalence of vitamin
A deficiency is based on Stevens et
al. (2015).4 Sub-regions with missing
data were conservatively assigned
a prevalence of 0. For each sub-
region, and assuming a 50 per cent
overlap between deficiencies, the
prevalence (P) of hidden hunger was
calculated as P(hidden hunger)= P(a)
+ 0.5*P(b), where P(a) and P(b) are
the maximum and minimum values,
respectively, when comparing iron
and vitamin A prevalence estimates.
Drawing on sub-region-specific
estimates of under-5 population sizes,
the global number of children <5
years affected was calculated and a
weighted global prevalence estimate
of hidden hunger was generated.5
‘What are young children eating?
The importance of first foods’
(pp. 74–75)The regional and global
estimates were generated using
the most recent data available for
each country between 2013 and
2018. UNICEF regional and global
estimates are population weighted
averages using the 2018 estimates
from the World Population Prospects,
2019 revision as weights.
180 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
Statistical tables
The statistical tables in this volume present the most recent key statistics on child survival, development and
protection for the world’s countries, areas and regions. They support UNICEF’s focus on progress and results
towards internationally agreed-upon goals and compacts relating to children’s rights and development.
General note on the data
Data sources
Data presented in the following statistical tables are derived
from the UNICEF global databases and are accompanied
by definitions, sources and, where necessary, additional
footnotes. The indicator data draw on inter-agency
estimates and nationally representative household surveys
such as Multiple Indicator Cluster Surveys (MICS) and
Demographic and Health Surveys (DHS). In addition, data
from administrative sources and other United Nations
organizations have been used. More detailed information
on the data sources is provided at the end of each table.
The demographic indicators and many of the population-
related indicators in these tables were based on the latest
population estimates and projections from World Population
Prospects: The 2019 revision and World Urbanization
Prospects: The 2018 revision (United Nations Department
of Economic and Social Affairs, Population Division). Data
quality is likely to be adversely affected for countries that
have recently suffered disasters or conflicts, especially
where basic country infrastructure has been fragmented
or where major population movements have occurred.
In particular, UNICEF assists countries in collecting and
analysing data for monitoring the situation of children
and women through its international household survey
initiative, the Multiple Indicator Cluster Surveys (MICS).
Since 1995, as many as 322 surveys have been completed
in more than 116 countries and areas. MICS was a major
source of data for monitoring progress on the Millennium
Development Goals (MDG) indicators and continues
to be a major data source during the 2030 Sustainable
Development Agenda to measure SDG indicators.
More information is available at <mics.unicef.org>.
Regional and global aggregates
Unless otherwise mentioned, regional and global aggregates
for indicators were generated as population weighted
averages using data from World Population Prospects: The
2019 revision. They accord with the relevant age and sex
group for each indicator (e.g. total live births for unweighted
at birth and number of females aged 15–49 years for
maternal anaemia). Again, unless otherwise noted, global
and regional estimates are only reported for indicators with
a population-level data coverage of at least 50 per cent.
Data comparability
Efforts have been made to maximize the comparability of
statistics across countries and time. Nevertheless, data
used at the country level may differ in terms of the methods
used to collect data or arrive at estimates, and in terms of
the populations covered. Furthermore, data presented here
are subject to evolving methodologies, revisions of time
series data (e.g., immunization, maternal mortality ratios),
and changing regional classifications. Also, data comparable
from one year to the next are unavailable for some
indicators. It is therefore not advisable to compare data from
consecutive editions of The State of the World’s Children.
Further methodological information
Data presented in the following statistical tables generally
reflect information compiled and updated from January
through August 2019, with specific cutoff time associated
with individual indicators described in the ‘Main data
sources’ section underneath each table. The ‘last updated’
time stamp reflects the time the data were compiled
and updated, as part of country consultation or inter-
agency processes that are specific to individual topics.
Interested readers are encouraged to visit <data.unicef.org>
for methodological details of the indicators and the statistics.
Data presented in the tables are available online at
<www.unicef.org/sowc> and via <www.data.unicef.
org>. Please refer to these websites for the latest data and
for any updates or corrigenda subsequent to printing.
 S tatistical ta b les » 1 8 1

Child mortality estimates

Under-five mortality is used as the principal indicator of progress in child well-being.

www.childmortality.org

Under-five mortality rate (deaths per 1,000 live births)

UNICEF Region 1980 1985 1990 1995 2000 2005 2010 2015 2018
East Asia and Pacific 73 62 57 49 40 29 22 17 15
Europe and Central Asia 44 37 31 27 21 16 12 10 9
Eastern Europe and Central Asia 66 54 46 45 36 26 19 15 13
Western Europe 16 13 10 8 6 5 4 4 4
Latin America and Caribbean 84 68 55 43 33 25 24 18 16
Middle East and North Africa 123 86 65 53 42 34 27 23 22
North America 15 12 11 9 8 8 7 7 6
South Asia 172 150 130 112 94 77 62 49 42
Sub-Saharan Africa 201 188 180 172 153 125 101 85 78
Eastern and Southern Africa 185 172 164 156 136 107 82 64 57
West and Central Africa 217 205 197 188 170 143 120 105 97
Least developed countries 211 192 175 159 137 110 89 71 64
World 118 102 93 87 76 63 51 42 39

Under-five deaths (thousands)

UNICEF Region 1980 1985 1990 1995 2000 2005 2010 2015 2018
East Asia and Pacific 2,622 2,416 2,302 1,706 1,259 910 696 542 462
Europe and Central Asia 571 483 387 305 218 164 135 111 96
Eastern Europe and Central Asia 474 410 329 263 188 138 112 92 78
Western Europe 97 74 57 41 30 26 23 20 18
Latin America and Caribbean 948 786 641 501 377 282 262 190 172
Middle East and North Africa 902 708 547 420 325 271 246 235 220
North America 55 50 47 40 35 35 32 29 27
South Asia 5,585 5,258 4,743 4,191 3,570 2,934 2,279 1,716 1,475
Sub-Saharan Africa 3,396 3,613 3,857 4,087 4,045 3,696 3,304 3,007 2,869
Eastern and Southern Africa 1,631 1,727 1,827 1,908 1,834 1,590 1,322 1,107 1,024
West and Central Africa 1,765 1,886 2,031 2,179 2,212 2,107 1,982 1,900 1,845
Least developed countries 3,580 3,619 3,605 3,558 3,330 2,895 2,508 2,136 1,992
World 14,080 13,314 12,524 11,250 9,831 8,292 6,955 5,828 5,322
182 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
Regional classifications
Aggregates presented at the end of each of the 16 statistical tables are calculated
using data from countries and areas as classified below.
East Asia and the Pacific
Australia; Brunei Darussalam; Cambodia; China; Cook
Islands; Democratic People’s Republic of Korea; Fiji;
Indonesia; Japan; Kiribati; Lao People’s Democratic
Republic; Malaysia; Marshall Islands; Micronesia (Federated
States of); Mongolia; Myanmar; Nauru; New Zealand;
Niue; Palau; Papua New Guinea; Philippines; Republic
of Korea; Samoa; Singapore; Solomon Islands; Thailand;
Timor-Leste; Tokelau; Tonga; Tuvalu; Vanuatu; Viet Nam
Europe and Central Asia
Eastern Europe and Central Asia; Western Europe
Eastern Europe and Central Asia
Albania; Armenia; Azerbaijan; Belarus; Bosnia and
Herzegovina; Bulgaria; Croatia; Georgia; Kazakhstan;
Kyrgyzstan; Montenegro; Republic of Moldova;
Romania; Russian Federation; Serbia; Tajikistan; North
Macedonia; Turkey; Turkmenistan; Ukraine; Uzbekistan
Western Europe
Andorra; Austria; Belgium; Cyprus; Czechia; Denmark;
Estonia; Finland; France; Germany; Greece; Holy See;
Hungary; Iceland; Ireland; Italy; Latvia; Liechtenstein;
Lithuania; Luxembourg; Malta; Monaco; Netherlands;
Norway; Poland; Portugal; San Marino; Slovakia; Slovenia;
Spain; Sweden; Switzerland; United Kingdom
Latin America and the Caribbean
Anguilla; Antigua and Barbuda; Argentina; Bahamas;
Barbados; Belize; Bolivia (Plurinational State of); Brazil;
British Virgin Islands; Chile; Colombia; Costa Rica; Cuba;
Dominica; Dominican Republic; Ecuador; El Salvador;
Grenada; Guatemala; Guyana; Haiti; Honduras; Jamaica;
Mexico; Montserrat; Nicaragua; Panama; Paraguay; Peru;
Saint Kitts and Nevis; Saint Lucia; Saint Vincent and the
Grenadines; Suriname; Trinidad and Tobago; Turks and
Caicos Islands; Uruguay; Venezuela (Bolivarian Republic of)
Middle East and North Africa
Algeria; Bahrain; Egypt; Iran (Islamic Republic of); Iraq;
Israel; Jordan; Kuwait; Lebanon; Libya; Morocco; Oman;
Qatar; Saudi Arabia; State of Palestine; Syrian Arab
Republic; Tunisia; United Arab Emirates; Yemen
North America
Canada; United States
South Asia
Afghanistan; Bangladesh; Bhutan; India;
Maldives; Nepal; Pakistan; Sri Lanka
Sub-Saharan Africa
Eastern and Southern Africa; West and Central Africa
Eastern and Southern Africa
Angola; Botswana; Burundi; Comoros; Djibouti; Eritrea;
Eswatini; Ethiopia; Kenya; Lesotho; Madagascar; Malawi;
Mauritius; Mozambique; Namibia; Rwanda; Seychelles;
Somalia; South Africa; South Sudan; Sudan; Uganda;
United Republic of Tanzania; Zambia; Zimbabwe
West and Central Africa
Benin; Burkina Faso; Cabo Verde; Cameroon; Central African
Republic; Chad; Congo; Côte d’Ivoire; Democratic Republic
of the Congo; Equatorial Guinea; Gabon; Gambia; Ghana;
Guinea; Guinea-Bissau; Liberia; Mali; Mauritania; Niger;
Nigeria; Sao Tome and Principe; Senegal; Sierra Leone; Togo
Least developed countries/areas
[Classified as such by the United Nations High
Representative for the Least Developed Countries,
Landlocked Developing Countries and Small
Island Developing States (UNOHRLLS)].
Afghanistan; Angola; Bangladesh; Benin; Bhutan; Burkina
Faso; Burundi; Cambodia; Central African Republic; Chad;
Comoros; Democratic Republic of the Congo; Djibouti;
Eritrea; Ethiopia; Gambia; Guinea; Guinea-Bissau; Haiti;
Kiribati; Lao People’s Democratic Republic; Lesotho; Liberia;
Madagascar; Malawi; Mali; Mauritania; Mozambique;
Myanmar; Nepal; Niger; Rwanda; Sao Tome and Principe;
Senegal; Sierra Leone; Solomon Islands; Somalia; South
Sudan; Sudan; Timor-Leste; Togo; Tuvalu; Uganda;
United Republic of Tanzania; Vanuatu; Yemen; Zambia

Notes on specific tables
TABLE 1. DEMOGRAPHICS
The demographics table contains selected indicators on the
most important demographic information of each population,
including the total population and population by age, as
well as annual population growth rates. Annual number
of births is a function of both population size and current
fertility. Total fertility rate allows for comparison of fertility
levels, internationally. A total fertility level of 2.1 is called
‘replacement level’ and represents a level at which, in the
long term, the population would remain the same size. Life
expectancy at birth is a measure of the health status and the
development of a population and continues to increase in
almost all countries in the world. The dependency ratio is the
ratio of the not-working-age population (i.e., the economically
‘dependent’ population) to the working-age population
(15–64 years) and can be divided into child dependency ratio
(ratio of children under 15 to working-age population) and
old-age dependency ratio (ratio of population 65 and older
to working-age population). Total dependency ratio is usually
U-shaped over time and development: high fertility leads
to a large share of the child population and consequently
to a high dependency ratio which then decreases with
decreasing fertility before increasing again due to increasing
life expectancy and an increasing older population share.
The proportion of the urban population and the annual urban
population growth rate describe the status and dynamic of
the urbanization process. The net migration rate refers to
the difference between the number of immigrants and the
number of emigrants; a country/area with more immigrants
than emigrants shows a positive value, while a country with
less immigrants than emigrants shows a negative value.
All demographic indicators are based on World Population
Prospects: The 2019 revision. Except for total population
size, most demographic indicators are published only for
countries/areas with a population greater than 90,000.
TABLE 2. CHILD MORTALITY
Each year, in The State of the World’s Children, UNICEF
reports a series of mortality estimates for children. These
figures represent the best estimates available at the
time of printing and are based on the work of the United
Nations Inter-agency Group for Child Mortality Estimation
(UN IGME), which includes UNICEF, the World Health
Organization (WHO), the World Bank group and the United
Nations Population Division. UN IGME mortality estimates
are updated annually through a detailed review of all newly
available data points, which often results in adjustments
S tatistical ta b les » 1 8 3
to previously reported estimates. As a result, consecutive
editions of The State of the World’s Children should not be
used for analysing mortality trends over time. Comparable
global and regional under-five mortality estimates for the
period 1990–2018 are presented below. Country-specific
mortality indicators, based on the most recent UN IGME
estimates, are presented in Table 2 and are available at
<data.unicef.org/child-mortality/under-five> and www.
childmortality.org, along with methodological notes.
TABLE 3. MATERNAL AND NEWBORN HEALTH
The maternal and newborn health table includes a
combination of demographic and intervention coverage
indicators. The demographic indicators consist of life
expectancy for females, adolescent birth rate, and maternal
mortality estimates including number of maternal deaths,
maternal mortality ratio, and lifetime risk of maternal death.
The life expectancy and adolescent birth rate indicators come
from the United Nations Population Division. The maternal
mortality data are estimates generated by the United Nations
Maternal Mortality Estimation Inter-Agency group (UN
MMEIG), which includes the World Health Organization
(WHO), UNICEF, United Nations Population Fund (UNFPA),
the World Bank Group, and the United Nations Population
Division. UN MMEIG mortality estimates are updated
regularly through a detailed review of all newly available
data points. This process often results in adjustments to
previously reported estimates. As a result, consecutive
editions of The State of the World’s Children should not be
used for analysing maternal mortality trends over time.
Intervention coverage indicators encompass indicators for
family planning, antenatal care, delivery care and postnatal
care for mother and baby. The data for these indicators
come from national household survey programmes such as
the DHS and MICS and other reproductive health surveys.
Regional and global estimates are calculated by using a
weighted average method. The variables used for weighting
are indicator-specific and applied to each country. They
accord with the appropriate target population for each
indicator (the denominator) and are derived from the latest
edition of the World Population Prospects. Only the most
recent data points from 2013–2018 for each country were
used to calculate regional and global aggregates. India and
China were included in the calculation of the regional and
global estimates for all indicators with available data.
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The maternal and newborn health table also includes some †† For BCG, regional averages include only
age disaggregations to provide information on adolescent those countries where BCG is included in the
reproductive and maternal health. Specifically, demand national routine immunization schedule.
for family planning satisfied with modern methods,
antenatal care of at least four visits, and skilled attendant †† For DTP, polio, measles, HepB, Hib, PCV and rotavirus
at birth are disaggregated for the 15–19 year age group. vaccines, regional averages include all countries, as
The disaggregated data for antenatal care of at least four these vaccines are universally recommended by WHO.
visits and skilled attendant at birth come from the Federal
†† For protection at birth (PAB) from tetanus, regional
University of Pelotas, International Center for Equity in
averages include only the countries where
Health, Brazil. The total and disaggregated data for demand
maternal and neonatal tetanus is endemic.
for family planning satisfied with modern methods come
from the United Nations Department of Economic and
TABLE 5 and 6. HIV/AIDS
Social Affairs Population Division. Regional and global
In 2019, the Joint United Nations Programme on HIV/AIDS
estimates are calculated with the same methodology
(UNAIDS) released new global, regional and country-level
described above for the intervention coverage indicators.
HIV and AIDS estimates for 2018 that reflect the most up-
to-date epidemiological estimates, as well as coverage data
TABLE 4. CHILD HEALTH
for antiretroviral therapy (ART), prevention of mother-to-child
The child health table includes a set of indicators
transmission (PMTCT) and early infant diagnosis for HIV. The
which capture information on the coverage of effective
estimates are based on the most current available science
interventions delivered to children under the age of
and WHO programme guidelines, which have resulted in
five years and at the household level. These include a
improvements in assumptions of the probability of HIV
range of immunization indicators (described below), and
transmission from mother-to-child, fertility among women
indicators on interventions for the prevention or treatment
by age and HIV serostatus, net survival rates for children
of pneumonia, diarrhoea and malaria (the three leading
living with HIV and more. Based on the refined methodology,
killers of young children). The main data sources for the
UNAIDS has retrospectively generated new estimates of
indicators on prevention and treatment of childhood illnesses
HIV prevalence, the number of people living with HIV and
are nationally representative household surveys such as
those needing treatment, AIDS-related deaths, new HIV
the DHS and MICS. Regional and global estimates are
infections, and other important trends in the HIV epidemic.
calculated by using a weighted average method. Variables
used for weighting are indicator-specific and applied to
Key indicators on the HIV response for children are divided
each country. They accord with the appropriate target
into two tables: Table 5. HIV/AIDS epidemiology and
population for each indicator (the denominator) and are
Table 6. HIV/AIDS interventions.
derived from the latest edition of the World Population
Prospects. Only the most recent data points from 2013–
TABLE 5. HIV/AIDS: EPIDEMIOLOGY
2018 for each country were used to calculate regional and
Table 5 includes key indicators that are used to measure
global estimates. For indicators that capture information
trends in the HIV epidemic. Data are disaggregated by
about households, total population was used. India and
10-year age groups, as children living with HIV under
China were included in the calculation of the regional and
age 10 are all assumed to be infected through mother-to-
global estimates for all indicators with available data.
child transmission. Children aged 10–19 living with HIV
additionally include new HIV infections that occur through
Immunization
sexual transmission and injection drug use, depending on
The child health table presents the WHO and UNICEF
the country context. Due to significant gender disparity
estimates of national immunization coverage. Since 2000,
among adolescents evident in HIV epidemic trends
these estimates have been updated annually in July,
and programmatic response, disaggregates by sex are
following a consultation process during which countries
now included for all HIV/AIDS epidemiology indicators.
are provided with draft reports for review and comment.
For better comparison between countries and regions,
As new empirical data are incorporated into the process for
the indicator on the number of new HIV infections has
generating the estimates, the revised estimates supersede
been replaced with HIV incidence per 1,000 uninfected
prior data releases. Coverage levels from earlier revisions are
population. Similarly, the number of AIDS-related deaths
not comparable. A more detailed explanation of the process
has been replaced with AIDS-related mortality per 100,000
can be found at <data.unicef.org/child-health/immunization>.
population. These two indicators provide relative measures
of new HIV infections and AIDS-related deaths and more
Regional averages for the reported antigens are computed
accurately demonstrate the impact of the HIV response.
as follows:

TABLE 6. HIV/AIDS: INTERVENTIONS
Table 6 includes indicators on essential interventions
in the HIV response for children. These coverage
indicators have been revised from previous editions
of The State of the World’s Children to better reflect
progress in current HIV/AIDS programmes and policy.
For example, the indicator for early infant HIV diagnosis
captures information on what percentage of HIV-
exposed infants received an HIV test within two months
of birth. All coverage indicators are calculated from the
most recent and reliable data available from population-
based surveys and programme service statistics.
Each coverage indicator is aggregated regionally or globally
using a population-weighted average. Due to sometimes
sparse data, indicators from population-based surveys
are only aggregated if the data in that area represent
at least 50 per cent of the adolescent population.
TABLES 7 and 8. NUTRITION
Table 7 encompasses nutrition at birth and feeding practices
for infants and young children and Table 8 comprises
estimates of malnutrition among pre-school-aged children,
school-aged children and women of reproductive age as well
as intervention coverage of key micronutrient programmes.
Indicators of low birthweight, thinness and overweight
among school-aged children, and maternal underweight
and anaemia are modelled estimates and therefore
may be different from survey-reported estimates. For
all other indicators, when raw data were available,
the country-level estimates were re-analysed to
conform to standard analysis methods and may
therefore differ from survey-reported values.
Low birthweight : Estimates are based on new methods;
therefore country, regional and global estimates may
not be comparable with those published in previous
editions of The State of the World’s Children.
Unweighted at birth : A new indicator representing the
percentage of births without a birthweight in the data source.
Infant and young child feeding : A total of 8 indicators
are presented, including the following with recent definitional
changes or which are new: (i) Continued breastfeeding
(12–23 months) replaces 2 previous indicators of continued
breastfeeding at 1 year (12–15 months) and 2 years (20–23
months); (ii) Minimum Dietary Diversity (MDD) (6–23
months) is now defined as the percentage of children
6–23 months of age who received foods from at least
5 out of 8 defined food groups during the previous day
(the older version of this indicator reflected consumption
of at least 4 out of 7 defined food groups during the
previous day); (iii) Minimum Acceptable Diet (MAD) (6–23
S tatistical ta b les » 1 8 5
months) is revised to align with the change to the MDD
definition and (iv) Zero vegetable or fruit consumption
(6–23 months) is a new indicator. The indicator definition
of Minimum Meal Frequency (MMF) (6–23 months) was
also revised in 2018, but related changes to MMF and MAD
estimates have not yet been reflected in these tables.
Stunting, wasting and overweight : UNICEF,
WHO and the World Bank have continued a process to
harmonize anthropometric data used for computation
and estimation of regional and global averages and trend
analysis. As part of this process, regional and global
averages for stunting, wasting and overweight prevalence
are derived from a model described in M. de Onis et al
(2004), ‘Methodology for Estimating Regional and Global
Trends of Child Malnutrition’ (International Journal of
Epidemiology, 33, pp. 1260–1270). New global and regional
estimates are released every year, which supersede
all previous estimates and should not be compared.
Vitamin A supplementation : Emphasizing the
importance for children of receiving two annual doses of
vitamin A (spaced 4–6 months apart), this report presents
only full coverage of vitamin A supplementation. In the
absence of a direct method to measure this indicator,
full coverage is reported as the lower coverage estimate
from semester 1 (Jan–June) and semester 2 (July–Dec),
in a given year. The regional and global aggregates only
contain the 82 countries indicated as priority countries for
national-level programmes. Hence the regional aggregates
are published where at least 50 per cent of the population
coverage for the priority countries in each region has
been met. In other words, East Asia and Pacific estimates
are presented despite there being no data for China.
Malnutrition among school-aged children :
Indicators under this title reflect the importance of
ending malnutrition among children of all ages. Country
estimates for malnutrition among school-aged children
are based on the NCD Risk Factor Collaboration (NCD-
RisC) (2017), ‘Worldwide trends in body-mass index,
underweight, overweight, and obesity from 1975 to 2016:
a pooled analysis of 2416 population-based measurement
studies in 128.9 million children, adolescents, and
adults’, The Lancet, 390(10113), pp. 2627–2642.
Underweight women 18+ years : This indicator reflects
the importance of maternal malnutrition if malnutrition
among children is to be eliminated. Country estimates for
underweight women are based on the NCD Risk Factor
Collaboration (NCD-RisC) (2017), ‘Worldwide trends in body-
mass index, underweight, overweight, and obesity from
1975 to 2016: a pooled analysis of 2416 population-based
measurement studies in 128.9 million children, adolescents,
and adults’, The Lancet, 390(10113), pp. 2627–2642.
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Anaemia women 15–49 years : This indicator reflects the
importance of maternal malnutrition if malnutrition among
children is to be eliminated. Country estimates for anaemia
are based on WHO (2017), Global Health Observatory (GHO).
In: World Health Organization [online]. Geneva, Switzerland.
[Cited 1 August 2019] http://apps.who.int/gho/data/node.
imr.PREVANEMIA?lang=en; data for adult obesity are
based on WHO (2017), Global Health Observatory (GHO).
Iodized salt : The definition of the indicator presented
in this report has changed from the past, when it was
about households consuming adequately iodized salt.
Now it is about salt with any iodine, and therefore
global and regional average prevalence estimates are
not comparable to the averages published in previous
editions of The State of the World’s Children.
TABLE 9. EARLY CHILDHOOD DEVELOPMENT
Early childhood, which spans the period up to eight
years of age, is critical for cognitive, social, emotional
and physical development. Optimal brain development
requires a stimulating environment, adequate nutrients
and social interaction with attentive caregivers. The
early childhood development table presents data on
some specific indicators with comparable and nationally
representative data on the quality of care at home, access
to learning materials at home, and access to early childhood
care and education. The information in this table is best
interpreted alongside data on other areas vital to early
childhood development such as nutrition and protection.
Early stimulation and responsive care by adults :
Data on this indicator from the DHS were recalculated
according to the MICS methodology for comparability.
Therefore, the recalculated data presented here will
differ from estimates in DHS national reports.
Early stimulation and responsive care by father :
Data from the third and fourth rounds of MICS (MICS3
and MICS4) refer to father’s engagement in one or more
activities to promote learning and school readiness, while the
definition was changed in the fifth round (MICS5) to reflect
father’s engagement in four or more activities. Therefore,
estimates of early stimulation and responsive care by fathers
from MICS3 and MICS4 are lower than those based on
results beginning with MICS5. Data on this indicator from the
DHS were recalculated according to the MICS methodology
for comparability. Therefore, the recalculated data presented
here will differ from estimates in DHS national reports.
Learning materials at home: Playthings: Changes
in the definition of this indicator were made between
the third and fourth round of MICS (MICS3 and MICS4).
In order to allow for comparability with MICS4 and
subsequent rounds of MICS, data from MICS3 were
recalculated according to the MICS4 indicator definition.
Therefore, the recalculated data presented here will differ
from estimates reported in MICS3 national reports.
Children with inadequate supervision : This
indicator was previously referred to as ‘children left
in inadequate care’ but has been renamed to more
accurately reflect the nature of the underlying construct.
TABLE 10: EDUCATION
This table contains a set of indicators on the following
aspects of education of children: equitable access,
school completion and learning outcomes.
In particular, indicators on school completion measure
children or young people aged 3–5 years above the
intended age for the last grade of each level of education
who have completed that grade. Completion rate indicates
how many school-age children in a given age group have
completed the relevant level of education. By choosing
an age group which is slightly older than the theoretical
age group for completing each level of education, the
indicator measures how many children and adolescents
enter school more or less on time and progress through
the education system without excessive delays.
This table also includes a set of indicators to monitor
equitable learning outcomes, which is a target (4.1) of
Sustainable Development Goal 4. The minimum proficiency
level is the benchmark of basic knowledge in a domain
(i.e., mathematics and reading) measured through learning
assessment. The indicator shows data published by
national governments as well as agencies and organizations
specialized in cross-national learning assessments.
Detailed information on the indicators included in this
table can be found in UNESCO Institute for Statistics, July
2017. Metadata for the global and thematic indicators for
the follow-up and review of SDG4 and Education 2030.
TABLE 11. CHILD PROTECTION
Child protection refers to prevention and response to
violence, exploitation and abuse of children in all contexts.
There are many different child protection violations that
children can be subjected to but the lack of comparable
data limits reporting on the full spectrum. In view of this,
the child protection table presents data on a few issues
for which comparable and nationally representative
data are available. This includes two manifestations of
harmful traditional practices, some forms of violence and
exploitation as well as the official recording of births.
Birth registration : Changes in the definition of birth
registration were made from the second and third rounds of
MICS (MICS2 and MICS3) to the fourth round (MICS4). In
order to allow for comparability with later rounds, data from
MICS2 and MICS3 on birth registration were recalculated

according to the MICS4 indicator definition. Therefore,
the recalculated data presented here may differ from
estimates included in MICS2 and MICS3 national reports.
Child labour : This indicator has been replaced by the
one used for SDG reporting on indicator 8.7.1 and reflects
the proportion of children engaged in economic activities
and/or household chores at or above age-specific hourly
thresholds (general production boundary basis):
Child labour for the 5 to 11 age range: children working at
least 1 hour per week in economic activity and/or involved in
unpaid household services for more than 21 hours per week;
Child labour for the 12 to 14 age range: children working for at
least 14 hours per week in economic activity and/or involved in
unpaid household services for more than 21 hours per week;
Child labour for the 15 to 17 age range: children
working for more than 43 hours per week in
economic activity. No hourly threshold is set for
unpaid household services for ages 15–17.
Country estimates compiled and presented in the
global SDG database and reproduced in SOWC have
been re-analysed by UNICEF and ILO in accordance
with the definitions and criteria detailed above. This
means that the country data values will differ from
those published in national survey reports.
Child marriage : While the practice is more widespread
among girls, marriage in childhood is a rights violation for
both sexes. Therefore, the prevalence of child marriage
is shown among both males and females. For males,
only marriage before age 18 is shown, as marriage
before age 15 is exceedingly rare. For females, the
global aggregate is calculated as a population-weighted
average of the prevalence in each region; for more details
about special considerations and assumptions used in
these calculations, refer to Child Marriage: Latest trends
and future prospects, UNICEF, New York, 2018.
Female genital mutilation (FGM) : Data on the
prevalence of FGM among girls aged 0–14 years were
recalculated for technical reasons and may differ from
those presented in original DHS and MICS country reports.
Beginning with this edition of SOWC, attitudes towards the
practice are shown as the share of the population opposing
(rather than supporting) FGM, and this measure is now
shown among both males and females. Regional estimates
on the prevalence of FGM and attitudes towards the practice
are based on available data only from practising countries
with nationally representative data and therefore reflect the
situation among those living in these affected countries
within the region, and not the region as a whole, as there
are some non-practising countries in each region as well.
S tatistical ta b les » 1 8 7
Justification of wife-beating among adolescents :
Beginning with this edition of SOWC, the age
group used for reporting on this indicator has been
revised to refer to adolescents aged 15–19.
Violent discipline : Estimates used in UNICEF publications
and in MICS country reports prior to 2010 were calculated
using household weights that did not take into account
the last-stage selection of children for the administration
of the child discipline module in MICS surveys. (A random
selection of one child within the reference age group is
undertaken for the administration of the child discipline
module.) In January 2010, it was decided that more
accurate estimates are produced by using a household
weight that takes the last-stage selection into account.
MICS3 data were recalculated using this approach.
Additionally, the reference age group for this indicator
was revised beginning with MICS5 to children aged 1–14.
Therefore, estimates from MICS3 and MICS4 are not
directly comparable since they refer to children aged 2–14.
TABLE 12. SOCIAL PROTECTION AND EQUITY
This table provides information about social protection
coverage and the magnitude of income inequality, both
of which impact the context in which children live. Social
protection indicators include Mothers with newborns
receiving cash benefits, Proportion of children covered
by social protection and Distribution of Social Protection
Benefits (1st quintile, 5th quintile, bottom 40%). While
the first two indicators capture the coverage of social
protection, the third indicator reflects both incidence and
distribution across quintiles. The table gives an overview
of the social safety net that households – children in
particular – have access to within each country.
Inequality indicators include Share of household income
(1st quintile, 5th quintile, bottom 40%), Gini index, Palma
index and GDP per capita. The first indicator captures
the share of national income each quintile earns within a
country. It illustrates the structure of income distribution per
country while the Gini coefficient expresses the extent of
inequality and how it deviates from a perfectly equal income
distribution. In contrast, the Palma index concentrates on
the income difference between the share of the richest
10 per cent and the poorest 40 per cent of a population.
This indicator is more sensitive to the tails of distribution
and extreme inequalities. Because changes in income
inequality are mainly driven by changes in the income of the
richest 10 per cent and the poorest 40 per cent, the Palma
index offers insights on distributional changes of income
inequality. GDP per capita complements those indicators as
it measures the average standard of living of each country.
188 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9
The Social Protection and Equity indicators data have
an annual frequency and are extracted from the World
Bank’s World Development Indicators, the Atlas of
Social Protection – Indicators of Resilience and Equity
and the ILO’s World Social Protection Report.
TABLE 13. WASH
This table contains a set of indicators on access to basic
water, sanitation and hygiene services in households,
schools and health care facilities. The drinking water,
sanitation and hygiene estimates in this report come
from the WHO/UNICEF Joint Monitoring Programme
for Water Supply, Sanitation and Hygiene (JMP). Full
details of the JMP indicator definitions, data sources and
methods used to produce national, regional and global
estimates can be found at <www.washdata.org>. New
estimates are released every two years which supersede
all previous estimates and should not be compared.
TABLE 14. ADOLESCENTS
The adolescent table presents a selection of indicators on
the well-being of adolescents across various domains of
their lives: Health, Protection, Education and learning and
Transition to work. While adolescent well-being is broad
and cannot be exhaustively captured in a small selection
of indicators, the measures in Table 14 are meant to serve
as an illustrative sample, and to complement adolescent-
relevant indicators which appear throughout the other
statistical tables in this publication. The indicators are
drawn from the Adolescent Country Tracker, a multi-
stakeholder framework grounded in the Sustainable
Development Goals which was developed to track
adolescent well-being across countries and over time.
NEET and Unemployment : Data on the degree to which
adolescents are able to effectively transition to work,
illustrated through the measures of those not in employment,
education or training (NEET) and the unemployment rate
among adolescents aged 15 to 19 years, are drawn from
the International Labour Organization (ILO). Metadata
and further notes on interpretation of these indicators are
available through the ‘Metadata’ section of <ilo.org/ilostat>.
TABLE 15. ECONOMIC INDICATORS
This table presents a macroeconomic overview of the
context affecting children’s well-being and development.
The indicators included in the table have two descriptive
purposes: they reflect the government’s fiscal space
to finance welfare programmes – as captured by
the Government Revenue and Official Development
Assistance (ODA) inflows; and they display the
government expenditure’s allocation on key sectors such
as health, education, social protection, and foreign aid
for DAC member countries. Government expenditure is
given in proportion to each country’s GDP and overall
public budget. This distinction highlights the relative
importance and size of each sector for social policy.
A similar distinction is operated for ODA between
inflows/outflows in million US$ and inflows/outflows in
proportion to each country’s Gross National Income.
The Economic Indicators data have an annual frequency and
are extracted from the World Bank’s World Development
Indicators, with the exception of ODA (inflows and outflows).
The data for this indicator come from the OECD. Due
to a lack of data coverage, government expenditure on
social protection as a percentage of government budget
is calculated by the authors. It represents the ratio of
government expenditure on social protection as a percentage
of GDP over government revenue as a percentage of GDP.
TABLE 16. WOMEN’S ECONOMIC EMPOWERMENT
This table has been added in 2019 in recognition of the
beneficial effects of women’s economic empowerment on
the well-being of children as well as to reflect the intrinsic
importance of women’s economic empowerment as
articulated in Sustainable Development Goal 5: Achieve
Gender Equality and Empower all Women and Girls.
Social Institutions and Gender Index (SIGI) : The SIGI,
a composite measure of gender discrimination in social
institutions produced by the Organisation for Economic
Co-operation and Development, is based on qualitative
and quantitative data through information on formal and
informal laws, attitudes and practices. Discriminatory laws,
attitudes and practices affect the life course of women
and girls, restricting their ability to accumulate human,
social and productive assets and to exercise agency
and voice over choices that affect their well-being.
Legal frameworks that promote, enforce and monitor
gender equality in employment and economic
benefits : Equality and non-discrimination on the basis
of sex are core principles under the international legal
and policy framework, including the Convention on the
Elimination of All Forms of Discrimination against Women
(CEDAW) and the Beijing Platform for Action. Removing
discriminatory laws and putting in place legal frameworks
that advance gender equality in employment and economic
benefits are prerequisites to increasing women’s paid work
and decent working conditions and, in turn, their economic
empowerment. The term ‘legal frameworks’ is defined
broadly to encompass laws, mechanisms and policies/
plans to promote, enforce and monitor gender equality. Data
derived for this indicator, SDG 5.1.1, are from an assessment
of a country’s legal frameworks completed by National
Statistical Offices and/or National Women’s Machinery,
and legal practitioners/researchers on gender equality.

Maternity/paternity leave benefits : Parental leave
benefits are critical for supporting the health and well-
being of children and women’s economic empowerment,
including infants’ survival and healthy development and
increased labour force participation and earnings for
women. ILO Convention No. 183 provides for 14 weeks of
paid maternity benefit to women to whom the instrument
applies. While no ILO standard exists specifically on
paternity leave, paternity benefits permit working fathers
to be more involved in the care of their children and the
sharing of household responsibilities. It is important to note,
however, that even in countries with legal rights to parental
leave, not all workers will have access, such as those
employed part-time or employed in the informal economy.
Demand for family planning satisfied with modern
methods : Access to and use of an effective means
to prevent pregnancy helps enable women and their
partners to exercise their rights to decide freely and
responsibly the number and spacing of children. As
measured by SDG Indicator 3.7.1, modern methods of
contraception include female and male sterilization, the
intra-uterine device (IUD), the implant, injectables, oral
contraceptive pills, male and female condoms, vaginal
barrier methods (including the diaphragm, cervical cap
and spermicidal foam, jelly, cream and sponge), lactational
amenorrhea method (LAM), emergency contraception
and other modern methods not reported separately (e.g.,
the contraceptive patch or vaginal ring). To foster cross-
country comparability, information for married or in-union
women is reported since not all countries collect the
information for all women, irrespective of marital status.
Educational attainment : While primary education
provides children with the foundation for a lifetime of
learning, secondary education equips them with the
knowledge and skills needed to become economically
empowered adults. Compared to girls with only a
primary education, girls with secondary education are
less likely to marry as children and become pregnant as
adolescents. And while women with primary education
earn only marginally more than women with no education,
women with secondary education earn twice as much,
on average, than women who have not gone to school
(see Wodon et al (2018), ‘Missed Opportunities: The High
Cost of Not Educating Girls’, The Cost of Not Educating
Girls Notes Series. The World Bank, Washington DC).
Labour force participation and unemployment rates :
Equal access to the labour market is critical for women’s
economic empowerment. The labour force participation rate
is calculated by expressing the number of persons in the
labour force during a given reference period as a percentage
of the working-age population (usually aged 15 and above) in
S tatistical ta b les » 1 8 9
the same reference period. The unemployment rate conveys
the percentage of persons (usually persons aged 15 and
above) in the labour force who are unemployed, reflecting
the inability of an economy to generate employment
for those persons who want to work but are not doing
so even though they are available for employment and
actively seeking work. Information on unemployment by
sex highlights the greater difficulty, in many cases, that
women have in entering the labour market, which can be
directly or indirectly linked to a country’s gender norms.
Mobile phone ownership : Mobile phone ownership
provides individuals with access to information, financial
services, employment opportunities and social networks
and, as such, is an important asset for fostering women’s
economic empowerment as recognized under Goal 5 of
the 2030 Agenda. As measured by SDG Indicator 5.b.1,
an individual owns a mobile cellular phone if he/she has a
mobile cellular phone device with at least one active SIM
card for personal use. Mobile cellular phones supplied by
employers that can be used for personal reasons (to make
personal calls, access the Internet, etc.) are included.
Individuals who have only active SIM card(s) and not a
mobile phone device are excluded. Individuals who have a
mobile phone for personal use that is not registered under
his/her name are also included. An active SIM card is a
SIM card that has been used in the last three months.
Financial inclusion : Measuring women’s access to
financial services, such as savings, insurance, payments,
credit and remittances, is essential for understanding their
economic empowerment. Access to financial services can
also increase women’s bargaining power in the household,
with potential benefits for the well-being of children. As
measured by SDG Indicator 8.10.2, an account at a financial
institution includes respondents who report having an
account at a bank or at another type of financial institution,
such as a credit union, microfinance institution, cooperative,
or the post office (if applicable), or having a debit card in their
own name. In addition, it includes respondents who report
receiving wages, government transfers, or payments for
agricultural products into an account at a financial institution
in the past 12 months; paying utility bills or school fees from
an account at a financial institution in the past 12 months;
or receiving wages or government transfers into a card
in the past 12 months. Mobile money account includes
respondents who report personally using GSM Association
(GSMA) Mobile Money for the Unbanked (MMU) services in
the past 12 months to pay bills or to send or receive money.
In addition, it includes respondents who report receiving
wages, government transfers, or payments for agricultural
products through a mobile phone in the past 12 months.
19 0 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

Number of under-five deaths and under-five

mortality by country in 2018
Table ordered by the number of unrounded number of deaths. Lower and Upper bound refer to the lower and upper bound of 90% uncertainty intervals

HIGHEST BURDEN OF DEATH AMONG CHILDREN UNDER-5

Under–5 mortality rate Under–5 mortality rate

Annual number of (deaths per 1,000 live births) Annual number of (deaths per 1,000 live births)
Countries under–5 deaths Lower Upper Countries under–5 deaths Lower Upper
and areas (thousands) Median bound bound and areas (thousands) Median bound bound

India 882 37 33 40 Morocco 15 22 17 29

Nigeria 866 120 97 151 Uzbekistan 15 21 17 27
Pakistan 409 69 56 85 Turkey 14 11 9 12
Democratic Republic of the Congo 296 88 59 129 Rwanda 13 35 21 59
Ethiopia 191 55 45 69 Russian Federation 13 7 6 8
China 146 9 8 10 Venezuela (Bolivarian Republic of) 13 25 21 29
Indonesia 121 25 22 29 Liberia 11 71 50 102
United Republic of Tanzania 107 53 41 69 Guatemala 11 26 21 34
Angola 94 77 36 144 Papua New Guinea 11 48 38 60
Bangladesh 89 30 27 33 Mauritania 11 76 40 143
Niger 83 84 56 125 Colombia 10 14 11 19
Sudan 80 60 46 79 Cambodia 10 28 15 50
Mozambique 79 73 53 104 Tajikistan 10 35 24 51
Mali 75 98 81 117 Congo 9 50 31 83
Chad 75 119 92 150 Peru 8 14 11 19
Afghanistan 74 62 50 75 Lao People's Democratic Republic 8 47 36 61
Uganda 74 46 37 59 Argentina 8 10 10 11
Somalia 73 122 65 233 Syrian Arab Republic 7 17 13 25
Côte d'Ivoire 70 81 66 99 Bolivia (Plurinational State of) 7 27 21 34
Cameroon 66 76 60 96 Thailand 7 9 8 12
Philippines 63 28 22 36 Democratic People's Republic of
6 18 14 23
Korea
Kenya 60 41 31 55
Turkmenistan 6 46 19 101
Burkina Faso 56 76 55 105
Dominican Republic 6 29 21 41
Egypt 55 21 16 29
Guinea-Bissau 5 81 53 121
Yemen 47 55 35 84
Gambia 5 58 34 98
Madagascar 45 54 40 71
Ecuador 5 14 13 15
Guinea 44 101 81 128
Lesotho 5 81 57 113
Myanmar 43 46 33 62
Eritrea 4 42 26 67
Brazil 42 14 13 17
Saudi Arabia 4 7 6 9
Ghana 41 48 40 58
Malaysia 4 8 7 8
South Africa 40 34 30 38
Kazakhstan 4 10 10 10
South Sudan 38 99 44 186
Ukraine 4 9 8 10
Benin 38 93 82 106
Azerbaijan 4 22 14 32
Zambia 36 58 44 76
Honduras 4 18 12 26
Viet Nam 33 21 17 25
Equatorial Guinea 4 85 51 134
Malawi 30 50 35 70
Jordan 3 16 13 21
Iraq 29 27 21 34
Tunisia 3 17 16 18
Mexico 28 13 12 13
United Kingdom 3 4 4 5
Sierra Leone 26 105 85 128
France 3 4 4 4
United States 25 7 6 7
Kyrgyzstan 3 19 18 20
Burundi 25 58 40 85
Gabon 3 45 29 69
Algeria 24 23 22 25
State of Palestine 3 20 15 28
Senegal 23 44 34 57
Paraguay 3 20 11 38
Iran (Islamic Republic of) 22 14 9 23
Germany 3 4 3 4
Zimbabwe 21 46 32 65
Namibia 3 40 25 65
Central African Republic 19 116 70 192
Sri Lanka 3 7 6 9
Nepal 18 32 25 41
Nicaragua 2 18 17 19
Togo 18 70 53 92
Japan 2 2 2 3
Haiti 17 65 51 84
 S tatistical ta b les » 1 9 1

About 15,000 children under

5 years old still die every day

LOWEST BURDEN OF DEATH AMONG CHILDREN UNDER-5

Under–5 mortality rate Under–5 mortality rate

Annual number of (deaths per 1,000 live births) Annual number of (deaths per 1,000 live births)
Countries under–5 deaths Lower Upper Countries under–5 deaths Lower Upper
and areas (thousands) Median bound bound and areas (thousands) Median bound bound

Botswana 2 36 16 73 Denmark 0 4 4 5
Canada 2 5 5 5 Ireland 0 4 3 5
Comoros 2 67 34 142 Vanuatu 0 26 17 42
Chile 2 7 6 9 North Macedonia 0 10 8 12
Timor-Leste 2 46 28 74 Cabo Verde 0 19 16 25
Poland 2 4 4 5 Sao Tome and Principe 0 31 20 49
Eswatini 2 54 35 82 Mauritius 0 16 14 17
El Salvador 2 14 9 21 Suriname 0 19 9 40
Libya 2 12 8 18 Qatar 0 7 6 8
Italy 1 3 3 3 Croatia 0 5 4 5
Romania 1 7 6 9 Kiribati 0 53 32 86
Mongolia 1 16 10 25 Bosnia and Herzegovina 0 6 5 7
Republic of Korea 1 3 3 4 Bahrain 0 7 6 9
Spain 1 3 3 3 Norway 0 3 2 3
Djibouti 1 59 37 94 Singapore 0 3 2 3
Panama 1 15 9 28 Lithuania 0 4 4 5
Australia 1 4 4 4 Belize 0 13 12 15
Oman 1 11 11 12 Finland 0 2 2 2
Lebanon 1 7 4 14 Latvia 0 4 3 5
United Arab Emirates 1 8 7 9 Micronesia (Federated States of) 0 31 13 75
Jamaica 1 14 9 25 Samoa 0 16 11 22
Netherlands 1 4 4 4 Brunei Darussalam 0 12 10 13
Republic of Moldova 1 16 12 21 Maldives 0 9 7 11
Israel 1 4 4 4 Bahamas 0 10 8 13
Costa Rica 1 9 8 10 Marshall Islands 0 33 22 50
Cuba 1 5 4 6 Slovenia 0 2 2 3
Georgia 1 10 8 12 Tonga 0 16 9 26
Armenia 1 12 9 16 Barbados 0 12 9 17
Fiji 0 26 24 28 Estonia 0 3 2 3
Guyana 0 30 19 48 Saint Lucia 0 17 13 22
Serbia 0 6 5 6 Dominica 0 36 28 46
Kuwait 0 8 7 9 Cyprus 0 2 2 3
Belgium 0 4 3 4 Malta 0 7 6 9
Bulgaria 0 7 7 8 Grenada 0 15 13 19
Solomon Islands 0 20 14 29 Saint Vincent and the Grenadines 0 16 13 20
Hungary 0 4 4 5 Seychelles 0 14 11 18
Belarus 0 3 3 4 Montenegro 0 3 2 3
Bhutan 0 30 19 44 Luxembourg 0 2 2 3
Czechia 0 3 3 4 Antigua and Barbuda 0 6 5 9
Greece 0 4 4 5 Nauru 0 32 18 55
Uruguay 0 8 7 8 Iceland 0 2 2 3
Switzerland 0 4 4 5 Saint Kitts and Nevis 0 12 9 16
New Zealand 0 6 5 7 Tuvalu 0 24 14 44
Trinidad and Tobago 0 18 8 43 Palau 0 18 10 34
Sweden 0 3 3 3 Andorra 0 3 2 5
Slovakia 0 6 5 6 Cook Islands 0 8 5 13
Austria 0 4 3 4 Monaco 0 3 2 5
Portugal 0 4 4 4 Niue 0 24 10 56
Albania 0 9 8 9 San Marino 0 2 1 4
 19 2 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 1. DEMOGRAPHICS
Life expectancy at Dependency ratio Annual growth rate of Net
Population (thousands) Annual population Annual Total birth (%) Proportion urban population migration
2018 growth rate (%) number of fertility (live (years) 2018 of urban (%) rate
Countries births births per
(thousands) woman) old
population
(%)
(per 1,000
population)
and areas total under 18 under 5 2000–2018 2018–2030α 2018 2018 1970 2000 2018 total child age 2018 2000–2018 2018–2030α 2015–2020

Afghanistan 37,172 18,745 5,601 3.2 2.1 1,207 4.5 37 56 64 84 79 5 25 4.0 3.4 -1.7
Albania 2,883 635 173 -0.5 -0.3 34 1.6 67 74 78 46 26 20 60 1.6 0.9 -4.9
Algeria 42,228 14,416 4,951 1.7 1.5 1,023 3.0 50 71 77 58 47 10 73 2.8 2.1 -0.2
Andorra 77 − − 0.9 0.1 − − − − − − − − 88 0.6 0.1 −
Angola 30,810 16,457 5,553 3.5 3.1 1,257 5.5 41 47 61 96 92 4 66 5.0 4.0 0.2
Anguilla 15 − − 1.5 0.6 − − − − − − − − 100 1.5 0.6 −
Antigua and Barbuda 96 26 7 1.3 0.7 1 2.0 66 74 77 45 32 13 25 -0.2 0.8 0.0
Argentina 44,361 13,103 3,748 1.0 0.8 755 2.3 66 74 77 56 39 17 92 1.2 1.0 0.1
Armenia 2,952 710 211 -0.2 0.0 41 1.8 70 71 75 47 30 17 63 -0.3 0.4 -1.7
Australia 24,898 5,664 1,627 1.5 1.0 318 1.8 71 80 83 53 29 24 86 1.6 1.2 6.4
Austria 8,891 1,539 434 0.5 0.3 88 1.5 70 78 81 50 21 28 58 0.4 0.8 7.4
Azerbaijan 9,950 2,708 872 1.1 0.6 167 2.1 63 67 73 42 33 9 56 1.6 1.4 0.1
Bahamas 386 106 26 1.4 0.8 5 1.8 66 72 74 42 32 10 83 1.5 1.0 2.6
Bahrain 1,569 353 108 4.8 2.1 22 2.0 63 74 77 28 25 3 89 4.8 2.2 31.1
Bangladesh 161,377 54,163 14,517 1.3 0.9 2,935 2.0 47 65 72 49 41 8 37 3.7 2.7 -2.3
Barbados 287 61 15 0.3 0.1 3 1.6 69 77 79 50 26 24 31 -0.2 0.5 -0.3
Belarus 9,453 1,855 566 -0.2 -0.2 111 1.7 71 67 75 46 25 22 79 0.4 0.3 0.9
Belgium 11,482 2,336 637 0.6 0.3 125 1.7 71 78 81 56 27 29 98 0.7 0.3 4.2
Belize 383 140 39 2.4 1.7 8 2.3 66 69 74 54 47 7 46 2.5 2.2 3.2
Benin 11,485 5,631 1,842 2.9 2.6 417 4.8 42 55 61 84 78 6 47 4.0 3.7 -0.2
Bhutan 754 237 63 1.4 0.9 13 2.0 40 61 71 47 38 9 41 4.0 2.4 0.4
Bolivia (Plurinational State of) 11,353 4,209 1,192 1.7 1.3 247 2.7 46 62 71 62 50 12 69 2.3 1.8 -0.8
Bosnia and Herzegovina 3,324 593 142 -0.7 -0.5 27 1.3 66 74 77 45 21 24 48 0.0 0.4 -6.4
Botswana 2,254 901 272 1.8 1.7 56 2.9 54 51 69 62 55 7 69 3.2 2.6 1.3
Brazil 209,469 54,592 14,654 1.0 0.6 2,915 1.7 59 70 76 43 31 13 87 1.4 0.8 0.1
British Virgin Islands 30 − − 2.1 0.5 − − − − − − − − 48 2.9 1.4 −
Brunei Darussalam 429 119 34 1.4 0.8 6 1.8 63 73 76 39 32 7 78 1.9 1.1 0.0
Bulgaria 7,052 1,213 313 -0.7 -0.8 63 1.6 71 72 75 55 23 33 75 -0.2 -0.4 -0.7
Burkina Faso 19,751 10,220 3,345 3.0 2.7 751 5.2 39 50 61 90 85 5 29 5.7 4.7 -1.3
Burundi 11,175 5,789 1,984 3.1 2.9 437 5.4 44 49 61 91 87 4 13 5.7 5.4 0.2
Cabo Verde 544 186 53 1.3 1.0 11 2.3 53 69 73 50 43 7 66 2.5 1.6 -2.5
Cambodia 16,250 5,943 1,774 1.6 1.2 365 2.5 42 58 70 56 49 7 23 2.9 3.0 -1.9
Cameroon 25,216 12,415 4,003 2.7 2.4 893 4.6 47 51 59 83 78 5 56 3.9 3.4 -0.2
Canada 37,075 7,060 1,954 1.1 0.8 386 1.5 73 79 82 49 24 26 81 1.2 1.0 6.6
Central African Republic 4,666 2,418 727 1.4 2.0 166 4.7 42 44 53 89 84 5 41 1.9 3.2 -8.6
Chad 15,478 8,375 2,815 3.4 2.8 654 5.7 41 48 54 98 94 5 23 3.8 4.2 0.1
Chile 18,729 4,450 1,203 1.1 0.3 231 1.6 62 76 80 46 29 17 88 1.2 0.4 6.0
China 1,427,648 304,793 85,912 0.6 0.2 16,824 1.7 59 71 77 40 25 15 59 3.3 1.7 -0.2
Colombia 49,661 14,032 3,730 1.3 0.6 736 1.8 62 73 77 46 34 12 81 1.7 1.0 4.2
Comoros 832 382 122 2.4 2.0 27 4.2 46 59 64 74 69 5 29 2.6 3.0 -2.4
Congo 5,244 2,522 805 2.9 2.4 173 4.4 51 52 64 80 75 5 67 3.6 3.1 -0.8
Cook Islands 18 − − -0.1 0.0 − − − − − − − − 75 0.7 0.3 −
Costa Rica 4,999 1,287 354 1.3 0.7 70 1.8 66 77 80 45 31 14 79 2.9 1.4 0.8
Côte d'Ivoire 25,069 12,228 3,973 2.3 2.5 898 4.6 44 50 57 81 76 5 51 3.2 3.4 -0.3
Croatia 4,156 723 189 -0.4 -0.6 37 1.4 68 75 78 54 22 31 57 0.0 0.1 -1.9
Cuba 11,338 2,233 608 0.1 -0.1 115 1.6 70 77 79 46 24 22 77 0.2 0.0 -1.3
Cyprus 1,189 243 65 1.3 0.6 12 1.3 73 78 81 44 24 20 67 1.1 0.7 4.2
Czechia 10,666 1,943 545 0.2 0.1 110 1.6 70 75 79 54 24 30 74 0.2 0.3 2.1
Democratic People's Republic of
25,550 6,309 1,744 0.6 0.4 355 1.9 60 65 72 42 29 13 62 0.8 0.8 -0.2
Korea
Democratic Republic of the Congo 84,068 44,282 15,185 3.2 3.0 3,468 5.9 44 50 60 97 91 6 44 4.5 4.2 0.3
Denmark 5,752 1,149 293 0.4 0.4 61 1.8 73 77 81 57 26 31 88 0.6 0.5 2.6
Djibouti 959 338 101 1.6 1.3 21 2.7 49 57 67 52 45 7 78 1.7 1.5 0.9
Dominica 72 − − 0.2 0.2 − − − − − − − − 70 0.6 0.6 −
Dominican Republic 10,627 3,552 1,009 1.3 0.9 207 2.3 58 69 74 54 43 11 81 2.8 1.5 -2.8
Ecuador 17,084 5,724 1,653 1.7 1.2 336 2.4 58 73 77 54 43 11 64 2.0 1.6 2.2
Egypt 98,424 38,430 12,972 2.0 1.7 2,591 3.3 52 69 72 64 55 9 43 2.0 2.1 -0.4
El Salvador 6,421 2,107 578 0.5 0.5 117 2.0 55 69 73 55 42 13 72 1.6 1.2 -6.3
Equatorial Guinea 1,309 556 191 4.3 3.0 44 4.5 40 53 58 65 61 4 72 6.4 3.6 12.4
Eritrea 3,453 1,659 483 2.3 1.7 105 4.1 43 55 66 86 78 8 40 4.6 3.2 -11.6
Estonia 1,323 253 68 -0.3 -0.3 14 1.6 70 70 79 56 26 31 69 -0.4 0.0 3.0
Eswatini 1,136 510 143 0.7 1.1 30 3.0 48 47 59 73 66 7 24 0.9 2.0 -7.4
Ethiopia 109,224 52,244 16,339 2.8 2.4 3,537 4.2 43 52 66 79 73 6 21 4.7 4.5 0.3
Fiji 883 305 91 0.5 0.7 19 2.8 62 66 67 54 45 8 56 1.4 1.6 -7.0
 S TAT I S T I C A L TA B L E S » 19 3

TABLE 1. DEMOGRAPHICS

Life expectancy at Dependency ratio Annual growth rate of Net

Population (thousands) Annual population Annual Total birth (%) Proportion urban population migration
2018 growth rate (%) number of fertility (live (years) 2018 of urban (%) rate
Countries births births per
(thousands) woman) old
population
(%)
(per 1,000
population)
and areas total under 18 under 5 2000–2018 2018–2030α 2018 2018 1970 2000 2018 total child age 2018 2000–2018 2018–2030α 2015–2020

Finland 5,523 1,068 279 0.3 0.1 51 1.5 70 78 82 61 26 35 85 0.6 0.2 2.5
France 64,991 14,005 3,734 0.5 0.2 729 1.9 72 79 83 61 29 32 80 0.9 0.5 0.6
Gabon 2,119 898 311 3.0 2.2 67 4.0 47 58 66 68 62 6 89 3.7 2.5 1.6
Gambia 2,280 1,159 393 3.0 2.7 88 5.2 38 56 62 88 83 5 61 4.4 3.7 -1.4
Georgia 4,003 922 279 -0.5 -0.3 54 2.1 67 70 74 53 30 23 59 0.1 0.4 -2.5
Germany 83,124 13,774 3,869 0.1 0.0 779 1.6 71 78 81 54 21 33 77 0.3 0.2 6.6
Ghana 29,767 13,045 4,104 2.4 2.0 876 3.9 49 57 64 69 63 5 56 3.8 3.0 -0.3
Greece 10,522 1,796 427 -0.3 -0.5 81 1.3 71 79 82 56 22 34 79 0.2 -0.1 -1.5
Grenada 111 31 9 0.4 0.3 2 2.1 66 73 72 50 35 14 36 0.5 0.9 -1.8
Guatemala 17,248 7,106 2,049 2.2 1.7 424 2.9 53 68 74 65 57 8 51 2.8 2.6 -0.5
Guinea 12,414 6,331 2,020 2.3 2.6 453 4.7 37 51 61 88 82 5 36 3.2 3.8 -0.3
Guinea-Bissau 1,874 915 298 2.5 2.3 66 4.5 41 50 58 82 77 5 43 3.5 3.2 -0.8
Guyana 779 266 76 0.2 0.4 16 2.5 62 65 70 53 43 10 27 -0.2 1.0 -7.7
Haiti 11,123 4,385 1,269 1.5 1.1 271 2.9 46 57 64 62 54 8 55 4.0 2.5 -3.2
Holy See 1 − − 0.1 -0.1 − − − − − − − − 100 0.1 -0.1 −
Honduras 9,588 3,670 1,003 2.1 1.5 207 2.5 53 71 75 57 50 7 57 3.4 2.5 -0.7
Hungary 9,707 1,690 448 -0.3 -0.3 92 1.5 69 72 77 51 22 29 71 0.3 0.1 0.6
Iceland 337 79 21 1.0 0.6 4 1.8 74 80 83 53 30 23 94 1.1 0.6 1.1
India 1,352,642 441,501 116,379 1.4 0.9 24,164 2.2 48 63 69 50 41 9 34 2.5 2.3 -0.4
Indonesia 267,671 85,121 24,350 1.3 0.9 4,834 2.3 53 66 72 48 39 9 55 2.8 2.0 -0.4
Iran (Islamic Republic of) 81,800 23,294 7,442 1.2 1.0 1,536 2.1 51 70 76 44 35 9 75 2.1 1.6 -0.7
Iraq 38,434 17,211 5,404 2.7 2.2 1,115 3.7 58 69 70 72 66 6 70 2.9 2.6 0.2
Ireland 4,819 1,212 329 1.3 0.7 62 1.8 71 77 82 54 33 21 63 1.7 1.2 4.9
Israel 8,382 2,733 846 1.9 1.5 170 3.0 72 79 83 66 46 20 92 2.0 1.6 1.2
Italy 60,627 9,797 2,443 0.4 -0.2 457 1.3 72 80 83 56 21 36 70 0.6 0.2 2.5
Jamaica 2,935 845 236 0.6 0.3 47 2.0 68 74 74 48 35 13 56 1.0 1.0 -3.9
Japan 127,202 19,592 5,051 0.0 -0.4 947 1.4 72 81 84 67 21 46 92 0.8 -0.3 0.6
Jordan 9,965 4,031 1,116 3.7 0.6 216 2.8 60 72 74 62 55 6 91 4.5 0.8 1.1
Kazakhstan 18,320 5,847 1,964 1.1 1.0 384 2.7 63 63 73 56 44 12 57 1.3 1.4 -1.0
Kenya 51,393 23,965 6,993 2.6 2.1 1,479 3.5 53 51 66 73 69 4 27 4.3 3.9 -0.2
Kiribati 116 47 15 1.8 1.5 3 3.6 52 63 68 65 59 7 54 3.0 2.7 -6.9
Kuwait 4,137 1,022 302 3.9 1.1 57 2.1 66 73 75 32 28 3 100 4.0 1.1 9.8
Kyrgyzstan 6,304 2,335 788 1.4 1.4 155 3.0 60 66 71 58 51 7 36 1.5 2.4 -0.6
Lao People's Democratic Republic 7,062 2,726 788 1.6 1.3 166 2.7 46 59 68 58 51 6 35 4.2 3.0 -2.1
Latvia 1,928 360 107 -1.2 -1.0 21 1.7 70 70 75 56 25 31 68 -1.2 -0.7 -7.6
Lebanon 6,859 2,149 617 3.2 -0.8 117 2.1 66 75 79 49 39 10 89 3.4 -0.7 -4.5
Lesotho 2,108 822 252 0.2 0.8 56 3.1 51 48 54 60 52 8 28 2.2 2.4 -4.8
Liberia 4,819 2,305 721 2.9 2.3 160 4.3 39 52 64 80 74 6 51 3.7 3.3 -1.0
Libya 6,679 2,223 642 1.2 1.1 126 2.2 56 71 73 49 42 7 80 1.5 1.4 -0.3
Liechtenstein 38 − − 0.7 0.3 − − − − − − − − 14 0.4 1.0 −
Lithuania 2,801 495 149 -1.2 -1.0 29 1.7 71 71 76 53 23 30 68 -1.2 -0.6 -11.6
Luxembourg 604 116 33 1.8 1.1 6 1.4 70 78 82 43 23 20 91 2.2 1.3 16.3
Madagascar 26,262 12,455 3,934 2.8 2.5 860 4.1 45 58 67 77 72 5 37 4.6 4.2 -0.1
Malawi 18,143 9,228 2,835 2.7 2.6 621 4.2 40 45 64 87 82 5 17 3.5 4.4 -0.9
Malaysia 31,528 9,191 2,606 1.7 1.1 528 2.0 65 73 76 44 35 10 76 2.8 1.7 1.6
Maldives 516 120 37 3.4 0.1 7 1.9 44 70 79 31 26 5 40 5.4 1.1 22.8
Mali 19,078 10,368 3,460 3.1 2.9 795 5.9 32 48 59 100 95 5 42 5.3 4.5 -2.1
Malta 439 75 22 0.6 0.2 4 1.5 71 79 82 53 22 31 95 0.7 0.2 2.1
Marshall Islands 58 − − 0.8 0.9 − − − − − − − − 77 1.4 1.3 −
Mauritania 4,403 2,040 669 2.9 2.5 148 4.6 50 61 65 76 71 6 54 4.8 3.8 1.2
Mauritius 1,267 283 66 0.4 0.0 13 1.4 63 71 75 41 25 16 41 0.1 0.3 0.0
Mexico 126,191 40,251 11,139 1.4 0.9 2,220 2.1 61 74 75 51 40 11 80 1.7 1.3 -0.5
Micronesia (Federated States of) 113 43 12 0.3 1.0 3 3.1 59 65 68 56 49 6 23 0.4 1.8 -5.4
Monaco 39 − − 1.0 0.6 − − − − − − − − 100 1.0 0.6 −
Mongolia 3,170 1,092 380 1.6 1.3 76 2.9 55 63 70 53 46 6 68 2.6 1.6 -0.3
Montenegro 628 138 37 0.1 0.0 7 1.7 70 73 77 50 27 22 67 0.9 0.4 -0.8
Montserrat 5 − − 0.1 -0.4 − − − − − − − − 9 8.2 0.3 −
Morocco 36,029 11,581 3,433 1.2 1.1 682 2.4 53 69 76 52 41 11 62 2.1 1.8 -1.4
Mozambique 29,496 15,238 4,944 2.8 2.8 1,110 4.9 41 49 60 91 85 6 36 4.0 4.2 -0.2
Myanmar 53,708 17,238 4,518 0.8 0.7 943 2.2 49 60 67 47 39 9 31 1.5 1.8 -3.1
Namibia 2,448 1,049 332 1.7 1.7 70 3.4 53 52 63 68 62 6 50 4.1 3.3 -2.0
Nauru 11 − − 0.2 0.2 − − − − − − − − 100 0.2 0.2 −
Nepal 28,096 10,490 2,721 0.9 1.4 563 1.9 41 62 70 57 48 9 20 3.0 3.5 1.5
Netherlands 17,060 3,362 873 0.4 0.2 172 1.7 74 78 82 55 25 30 91 1.4 0.5 0.9
 19 4 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 1. DEMOGRAPHICS

Life expectancy at Dependency ratio Annual growth rate of Net

Population (thousands) Annual population Annual Total birth (%) Proportion urban population migration
2018 growth rate (%) number of fertility (live (years) 2018 of urban (%) rate
Countries births births per
(thousands) woman) old
population
(%)
(per 1,000
population)
and areas total under 18 under 5 2000–2018 2018–2030α 2018 2018 1970 2000 2018 total child age 2018 2000–2018 2018–2030α 2015–2020

New Zealand 4,743 1,112 301 1.1 0.7 60 1.9 71 78 82 55 30 24 87 1.2 0.8 3.2
Nicaragua 6,466 2,316 664 1.4 1.1 133 2.4 54 70 74 55 47 8 59 1.7 1.6 -3.3
Niger 22,443 12,732 4,503 3.8 3.7 1,037 6.9 36 50 62 111 105 5 16 3.9 4.7 0.2
Nigeria 195,875 98,709 32,917 2.6 2.5 7,433 5.4 41 46 54 87 82 5 50 4.7 3.8 -0.3
Niue 2 − − -0.9 0.2 − − − − − − − − 45 0.8 1.5 −
North Macedonia 2,083 418 116 0.1 -0.1 23 1.5 66 73 76 43 24 20 58 0.1 0.5 -0.5
Norway 5,338 1,127 301 0.9 0.8 59 1.7 74 79 82 53 27 26 82 1.4 1.2 5.3
Oman 4,829 1,207 441 4.2 1.7 91 2.9 50 72 78 33 30 3 85 5.1 2.4 18.6
Pakistan 212,228 87,938 27,291 2.2 1.8 5,999 3.5 53 63 67 66 58 7 37 2.8 2.7 -1.1
Palau 18 − − -0.4 0.3 − − − − − − − − 80 0.4 0.8 −
Panama 4,177 1,342 389 1.8 1.4 79 2.5 66 75 78 54 42 13 68 2.3 1.9 2.7
Papua New Guinea 8,606 3,629 1,084 2.1 1.8 233 3.6 46 59 64 65 59 6 13 2.1 3.0 -0.1
Paraguay 6,956 2,446 693 1.5 1.1 143 2.4 65 71 74 56 46 10 62 2.1 1.7 -2.4
Peru 31,989 9,782 2,757 1.1 1.0 573 2.3 54 71 77 51 39 12 78 1.4 1.3 3.1
Philippines 106,651 39,276 11,035 1.7 1.2 2,191 2.6 63 69 71 56 48 8 47 1.8 1.9 -0.6
Poland 37,922 6,745 1,843 -0.1 -0.2 371 1.4 70 74 79 48 22 26 60 -0.2 0.0 -0.8
Portugal 10,256 1,699 413 0.0 -0.3 80 1.3 67 77 82 55 21 34 65 1.0 0.5 -0.6
Qatar 2,782 440 134 8.6 1.5 26 1.9 68 77 80 18 16 2 99 8.8 1.5 14.7
Republic of Korea 51,172 8,182 2,060 0.4 0.0 377 1.1 61 76 83 38 18 20 81 0.6 0.1 0.2
Republic of Moldova 4,052 765 210 -0.2 -0.3 41 1.3 65 67 72 38 22 16 43 -0.5 0.2 -0.3
Romania 19,506 3,626 930 -0.7 -0.5 189 1.6 68 70 76 51 23 28 54 -0.6 -0.1 -3.8
Russian Federation 145,734 30,223 9,497 0.0 -0.1 1,842 1.8 69 65 72 48 27 22 74 0.1 0.2 1.3
Rwanda 12,302 5,710 1,801 2.4 2.3 391 4.0 45 49 69 75 70 5 17 3.2 3.4 -0.7
Saint Kitts and Nevis 52 − − 1.0 0.5 − − − − − − − − 31 0.6 1.0 −
Saint Lucia 182 42 11 0.8 0.3 2 1.4 64 73 76 40 26 14 19 -1.4 1.0 0.0
Saint Vincent and the Grenadines 110 30 8 0.1 0.2 2 1.9 64 71 72 47 33 14 52 0.9 1.0 -1.8
Samoa 196 87 28 0.7 1.0 5 3.9 60 69 73 76 67 8 18 -0.4 0.5 -14.3
San Marino 34 − − 1.2 0.2 − − − − − − − − 97 1.4 0.3 −
Sao Tome and Principe 211 104 31 2.2 2.0 7 4.3 55 61 70 83 78 5 73 3.9 2.8 -8.0
Saudi Arabia 33,703 9,801 3,008 2.7 1.3 598 2.3 53 73 75 40 35 5 84 3.0 1.5 4.1
Senegal 15,854 7,853 2,557 2.7 2.6 548 4.6 39 58 68 86 80 6 47 3.5 3.6 -1.3
Serbia 8,803 1,691 422 -0.4 -0.5 83 1.5 68 72 76 52 24 28 56 -0.1 -0.1 0.5
Seychelles 97 27 8 1.0 0.5 2 2.4 66 71 73 45 34 11 57 1.7 1.2 -2.1
Sierra Leone 7,650 3,655 1,134 2.8 1.9 256 4.3 36 39 54 79 73 5 42 3.8 3.0 -0.6
Singapore 5,757 872 236 2.0 0.7 50 1.2 68 78 83 31 16 15 100 2.0 0.7 4.7
Slovakia 5,453 1,000 282 0.1 -0.1 57 1.5 70 73 77 45 22 23 54 -0.2 0.2 0.3
Slovenia 2,078 366 104 0.2 -0.1 20 1.6 69 76 81 53 23 30 55 0.6 0.5 1.0
Solomon Islands 653 304 101 2.5 2.3 21 4.4 56 67 73 78 72 6 24 4.8 4.0 -2.5
Somalia 15,008 8,056 2,673 2.9 2.9 629 6.1 41 51 57 98 92 6 45 4.6 4.1 -2.7
South Africa 57,793 19,702 5,796 1.4 1.1 1,184 2.4 53 56 64 52 44 8 66 2.2 1.8 2.5
South Sudan 10,976 5,316 1,702 3.2 1.9 387 4.7 36 49 58 83 76 6 20 4.1 3.7 -15.9
Spain 46,693 8,162 2,025 0.7 -0.1 394 1.3 72 79 83 52 22 29 80 1.0 0.2 0.9
Sri Lanka 21,229 6,132 1,690 0.7 0.3 336 2.2 64 71 77 53 37 16 18 0.7 1.4 -4.6
State of Palestine 4,863 2,202 690 2.3 2.2 143 3.6 56 71 74 73 67 5 76 2.6 2.6 -2.2
Sudan 41,802 19,758 6,158 2.4 2.3 1,347 4.4 52 58 65 79 72 6 35 2.7 3.5 -1.2
Suriname 576 187 53 1.1 0.8 11 2.4 63 68 72 52 41 10 66 1.1 1.0 -1.7
Sweden 9,972 2,067 591 0.6 0.5 119 1.9 74 80 83 60 28 32 87 0.9 0.8 4.0
Switzerland 8,526 1,523 444 1.0 0.6 88 1.5 73 80 84 50 22 28 74 1.0 0.8 6.1
Syrian Arab Republic 16,945 6,273 1,797 0.2 3.8 426 2.8 59 73 72 56 49 7 54 0.4 4.9 -24.1
Tajikistan 9,101 3,829 1,329 2.1 2.0 280 3.6 54 62 71 66 61 5 27 2.2 3.0 -2.2
Thailand 69,428 14,537 3,692 0.5 0.1 718 1.5 59 71 77 41 24 17 50 3.1 1.4 0.3
Timor-Leste 1,268 571 169 2.0 1.8 37 4.0 40 59 69 73 65 7 31 3.3 3.0 -4.3
Togo 7,889 3,781 1,189 2.6 2.3 262 4.3 47 53 61 79 74 5 42 3.9 3.6 -0.3
Tokelau 1 − − -0.9 0.8 − − − − − − − − 0 − − −
Tonga 103 43 12 0.3 0.9 3 3.6 64 70 71 71 60 10 23 0.3 1.2 -7.7
Trinidad and Tobago 1,390 337 92 0.5 0.1 18 1.7 65 69 73 45 30 16 53 0.2 0.4 -0.6
Tunisia 11,565 3,266 1,036 1.0 0.8 203 2.2 51 73 77 48 36 12 69 1.4 1.3 -0.3
Turkey 82,340 24,377 6,749 1.5 0.7 1,313 2.1 52 70 77 50 37 13 75 2.3 1.2 3.5
Turkmenistan 5,851 2,092 696 1.4 1.2 139 2.8 58 64 68 54 48 7 52 2.1 2.2 -0.9
Turks and Caicos Islands 38 − − 3.5 1.2 − − − − − − − − 93 4.0 1.4 −
Tuvalu 12 − − 1.1 1.1 − − − − − − − − 62 2.8 2.1 −
Uganda 42,729 23,085 7,538 3.3 2.8 1,627 5.0 49 46 63 96 92 4 24 5.9 5.0 4.0
Ukraine 44,246 8,152 2,250 -0.5 -0.7 421 1.4 71 67 72 48 23 24 69 -0.4 -0.4 0.2
 S TAT I S T I C A L TA B L E S » 19 5

TABLE 1. DEMOGRAPHICS

Life expectancy at Dependency ratio Annual growth rate of Net

Population (thousands) Annual population Annual Total birth (%) Proportion urban population migration
2018 growth rate (%) number of fertility (live (years) 2018 of urban (%) rate
Countries births births per
(thousands) woman) old
population
(%)
(per 1,000
population)
and areas total under 18 under 5 2000–2018 2018–2030α 2018 2018 1970 2000 2018 total child age 2018 2000–2018 2018–2030α 2015–2020

United Arab Emirates 9,631 1,633 502 6.2 0.8 100 1.4 61 74 78 19 17 1 87 6.7 1.1 4.2
United Kingdom 67,142 14,042 3,977 0.7 0.4 775 1.8 72 78 81 56 28 29 83 1.1 0.7 3.9
United Republic of Tanzania 56,313 28,558 9,316 2.9 2.8 2,071 4.9 47 51 65 88 83 5 34 5.2 4.7 -0.7
United States 327,096 73,857 19,512 0.8 0.6 3,912 1.8 71 77 79 53 29 24 82 1.1 0.8 2.9
Uruguay 3,449 860 239 0.2 0.3 48 2.0 69 75 78 55 32 23 95 0.4 0.4 -0.9
Uzbekistan 32,476 10,824 3,407 1.5 1.2 696 2.4 62 67 72 49 43 7 50 2.0 1.4 -0.3
Vanuatu 293 131 40 2.5 2.2 9 3.8 54 67 70 74 68 6 25 3.4 2.9 0.4
Venezuela (Bolivarian Republic of) 28,887 9,527 2,545 1.0 1.3 524 2.3 65 72 72 54 43 11 88 1.0 1.3 -22.3
Viet Nam 95,546 26,016 7,831 1.0 0.7 1,598 2.0 60 73 75 44 33 10 36 3.1 2.5 -0.8
Yemen 28,499 13,183 4,084 2.7 2.0 868 3.8 37 61 66 74 69 5 37 4.6 3.6 -1.1
Zambia 17,352 9,033 2,869 2.8 2.8 629 4.6 50 44 64 89 85 4 44 4.1 4.1 -0.5
Zimbabwe 14,439 7,082 2,196 1.1 1.6 443 3.6 57 45 61 83 78 5 32 0.8 2.2 -8.2

SUMMARY
East Asia and Pacific 2,363,341 558,205 156,967 0.7 0.4 30,995 1.8 59 71 76 44 28 15 59 2.7 1.5 -0.2
Europe and Central Asia 918,905 195,798 55,923 0.4 0.1 10,973 1.8 68 72 78 52 27 25 72 0.6 0.5 1.7
Eastern Europe and Central
423,215 103,676 31,140 0.4 0.2 6,107 2.0 64 66 73 49 31 18 67 0.6 0.6 0.7
Asia
Western Europe 495,690 92,123 24,782 0.4 0.1 4,866 1.6 71 78 82 55 24 31 77 0.6 0.4 2.6
Latin America and Caribbean 642,217 190,134 52,278 1.2 0.8 10,517 2.0 60 72 75 49 37 13 81 1.5 1.1 -0.8
Middle East and North Africa 447,891 155,635 49,580 2.0 1.5 10,121 2.8 52 70 74 54 46 8 65 2.6 2.0 -0.5
North America 364,296 80,943 21,472 0.9 0.6 4,300 1.8 71 77 79 52 28 24 82 1.1 0.8 3.3
South Asia 1,814,014 619,326 168,299 1.5 1.0 35,224 2.4 48 63 69 52 43 9 34 2.7 2.4 -0.7
Sub-Saharan Africa 1,080,429 530,744 171,759 2.7 2.5 38,074 4.7 44 50 61 84 78 5 40 4.0 3.7 -0.3
Eastern and Southern Africa 560,914 268,016 84,514 2.6 2.4 18,407 4.2 47 51 64 80 74 6 35 3.8 3.7 -0.3
West and Central Africa 519,515 262,729 87,245 2.8 2.6 19,667 5.2 42 49 58 88 83 5 46 4.3 3.8 -0.4
Least developed countries 1,009,691 464,463 145,155 2.4 2.2 31,786 4.0 44 55 65 75 69 6 34 4.0 3.7 -1.0
World 7,631,091 2,330,786 676,279 1.2 0.9 140,204 2.5 59 69 75 53 39 14 55 2.1 1.7 0.0
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES

Annual population growth rate – Average exponential rate
of growth of the population over one year. It is calculated as
ln(Pt/P0)/t where t is the length of the period. It is expressed
as a percentage.
Total fertility – The average number of live births a
hypothetical cohort of women would have at the end of their
reproductive period if they were subject during their whole
lives to the fertility rates of a given period and if they were not
subject to mortality. It is expressed as live births per woman.
Dependency ratios – The total dependency ratio is the ratio
of the sum of the population aged 0-14 and that aged 65+ to
the population aged 15-64. The child dependency ratio is the
ratio of the population aged 0-14 to the population aged 15-64.
The old-age dependency ratio is the ratio of the population
aged 65 years or over to the population aged 15-64. All ratios
are presented as number of dependants per 100 persons of
working age (15-64).
Life expectancy at birth – Number of years newborn
children would live if subject to the mortality risks prevailing
for the cross section of population at the time of their birth.
Proportion of urban population – Urban population as a
percentage of the total population.
Net migration rate – The number of immigrants minus
the number of emigrants over a period, divided by the
person-years lived by the population of the receiving country
over that period. It is expressed as net number of migrants per
1,000 population.
All demographic data – United Nations
Population Division. Proportion of urban
population for regions and growth rates
for total and urban population calculated
by UNICEF based on data from United
Nations Population Division: August 2019
(2018 for proportion of urban population).
NOTES
– Data not available.
α Based on medium-fertility variant
projections.
Regional and global values are based
on more countries and areas than
listed here. Therefore, country values
don’t add up to the corresponding
regional values and global value.
 19 6 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 2. CHILD MORTALITY

Annual Under-5 Probability of dying Neonatal Number of
rate of mortality rate by among children Annual Annual deaths as deaths
Under-5 mortality rate reduction sex (deaths per Infant mortality Neonatal mortality rate aged 5–14 (deaths number of number of proportion of among
(deaths per 1,000 live in under-5 1,000 live births) rate (deaths per (deaths per 1,000 live per 1,000 children under-5 neonatal all under-5 children
Countries births) mortality
rate (%)
2018 1,000 live births) births) aged 5) deaths deaths
(thousands) (thousands)
deaths
(%)
aged 5–14
(thousands)
and areas 1990 2000 2018 2000–2018 male female 1990 2018 1990 2000 2018 1990 2018 2018 2018 2018 2018

Afghanistan 179 129 62 4.1 66 59 121 48 75 61 37 16 5 74 45 60 5

Albania 41 26 9 6.0 9 8 35 8 13 12 7 7 2 0 0 74 0
Algeria 50 40 23 2.9 25 22 42 20 23 21 15 9 4 24 15 62 3
Andorra 11 6 3 4.4 3 3 9 3 6 3 1 7 1 0 0 50 0
Angola 223 206 77 5.4 83 71 132 52 54 51 28 46 16 94 36 38 15
Anguilla − − − − − − − − − − − − − − − − −
Antigua and Barbuda 28 16 6 5.0 7 6 24 5 15 9 3 5 1 0 0 50 0
Argentina 29 20 10 3.8 11 9 25 9 15 11 6 3 2 8 5 64 2
Armenia 49 31 12 5.1 14 11 42 11 23 16 6 3 2 1 0 52 0
Australia 9 6 4 2.9 4 3 8 3 5 4 2 2 1 1 1 62 0
Austria 10 6 4 2.5 4 3 8 3 5 3 2 2 1 0 0 60 0
Azerbaijan 96 75 22 6.9 24 19 76 19 33 34 11 5 3 4 2 51 0
Bahamas 24 16 10 2.4 11 9 20 8 13 8 5 4 2 0 0 53 0
Bahrain 23 13 7 3.2 7 7 20 6 15 5 3 4 2 0 0 43 0
Bangladesh 144 87 30 5.9 32 28 100 25 64 42 17 26 4 89 50 57 12
Barbados 18 15 12 1.2 13 11 16 11 12 9 8 3 2 0 0 65 0
Belarus 15 13 3 7.3 4 3 12 3 8 6 1 4 1 0 0 38 0
Belgium 10 6 4 2.6 4 3 8 3 5 3 2 2 1 0 0 56 0
Belize 38 24 13 3.3 14 12 31 11 19 12 9 5 3 0 0 67 0
Benin 175 139 93 2.2 99 87 106 61 46 40 31 45 22 38 13 35 7
Bhutan 127 78 30 5.3 32 27 89 25 43 32 16 20 7 0 0 56 0
Bolivia (Plurinational State of) 121 75 27 5.7 29 24 84 22 41 29 14 13 5 7 4 54 1
Bosnia and Herzegovina 18 10 6 2.9 6 5 16 5 11 7 4 3 1 0 0 69 0
Botswana 51 87 36 4.8 40 33 39 30 25 26 24 17 6 2 1 67 0
Brazil 63 35 14 4.9 16 13 53 13 25 18 8 5 2 42 24 57 7
British Virgin Islands − − − − − − − − − − − − − − − − −
Brunei Darussalam 13 10 12 -0.6 12 11 10 10 6 5 5 4 2 0 0 47 0
Bulgaria 18 18 7 5.0 8 6 15 6 8 8 4 4 2 0 0 51 0
Burkina Faso 199 179 76 4.7 81 72 99 49 46 41 25 40 20 56 19 33 11
Burundi 174 156 58 5.5 63 54 105 41 40 37 22 62 23 25 9 38 8
Cabo Verde 61 36 19 3.3 21 18 47 17 20 17 12 6 2 0 0 59 0
Cambodia 116 107 28 7.4 31 25 85 24 40 35 14 35 5 10 5 52 2
Cameroon 137 149 76 3.8 81 71 85 51 40 35 27 35 32 66 24 36 22
Canada 8 6 5 1.2 5 5 7 4 4 4 3 2 1 2 1 68 0
Central African Republic 180 172 116 2.2 123 110 117 84 52 49 41 32 15 19 7 36 2
Chad 212 186 119 2.5 125 112 112 71 52 44 34 53 28 75 22 30 13
Chile 19 11 7 2.3 8 7 16 6 9 5 5 3 1 2 1 67 0
China 54 37 9 8.1 9 8 42 7 29 21 4 8 2 146 73 50 40
Colombia 35 25 14 3.1 16 13 29 12 18 13 8 5 2 10 6 55 2
Comoros 125 102 67 2.3 73 62 88 51 50 41 32 18 9 2 1 48 0
Congo 90 114 50 4.6 54 46 59 36 27 31 20 37 7 9 3 41 1
Cook Islands 24 18 8 4.6 9 7 20 7 13 10 4 5 2 0 0 50 0
Costa Rica 17 13 9 2.2 10 8 14 8 9 8 6 3 2 1 0 67 0
Côte d'Ivoire 155 145 81 3.2 89 73 105 59 49 47 34 31 25 70 30 43 17
Croatia 13 8 5 3.2 5 4 11 4 8 6 3 3 1 0 0 55 0
Cuba 13 9 5 3.0 5 4 11 4 7 4 2 4 2 1 0 41 0
Cyprus 11 7 2 5.7 3 2 10 2 6 4 1 2 1 0 0 57 0
Czechia 12 5 3 2.7 4 3 10 3 7 3 2 2 1 0 0 52 0
Democratic People's Republic of
43 60 18 6.6 20 16 33 14 22 27 10 8 4 6 3 53 1
Korea
Democratic Republic of the Congo 186 161 88 3.3 95 81 119 68 42 39 28 41 29 296 98 33 70
Denmark 9 5 4 1.5 5 4 7 4 4 3 3 2 0 0 0 74 0
Djibouti 118 101 59 3.0 64 54 92 50 50 44 32 26 13 1 1 54 0
Dominica 16 15 36 -4.9 38 33 13 33 10 11 28 3 3 0 0 79 0
Dominican Republic 60 41 29 1.9 32 26 46 24 24 24 19 8 3 6 4 67 1
Ecuador 54 29 14 4.0 16 13 42 12 23 14 7 8 3 5 2 51 1
Egypt 86 47 21 4.4 22 20 63 18 33 23 11 11 4 55 29 53 9
El Salvador 60 33 14 4.9 15 12 46 12 23 15 7 7 4 2 1 49 0
Equatorial Guinea 179 157 85 3.4 91 79 121 63 48 45 30 38 18 4 1 36 1
Eritrea 153 86 42 4.0 47 36 94 31 35 27 18 45 9 4 2 44 1
Estonia 18 11 3 7.9 3 2 14 2 10 5 1 5 1 0 0 47 0
Eswatini 71 126 54 4.7 59 49 54 43 21 23 17 11 13 2 1 32 0
Ethiopia 202 142 55 5.2 61 49 120 39 59 49 28 78 12 191 99 52 34
Fiji 29 23 26 -0.7 28 23 24 22 12 9 11 10 5 0 0 42 0
Finland 7 4 2 5.1 2 2 6 1 4 2 1 2 1 0 0 55 0
 S TAT I S T I C A L TA B L E S » 19 7

TABLE 2. CHILD MORTALITY

Annual Under-5 Probability of dying Neonatal Number of

rate of mortality rate by among children Annual Annual deaths as deaths
Under-5 mortality rate reduction sex (deaths per Infant mortality Neonatal mortality rate aged 5–14 (deaths number of number of proportion of among
(deaths per 1,000 live in under-5 1,000 live births) rate (deaths per (deaths per 1,000 live per 1,000 children under-5 neonatal all under-5 children
Countries births) mortality
rate (%)
2018 1,000 live births) births) aged 5) deaths deaths
(thousands) (thousands)
deaths
(%)
aged 5–14
(thousands)
and areas 1990 2000 2018 2000–2018 male female 1990 2018 1990 2000 2018 1990 2018 2018 2018 2018 2018

France 9 5 4 1.6 4 4 7 3 4 3 3 2 1 3 2 62 1
Gabon 93 85 45 3.5 49 40 60 33 31 29 21 19 14 3 1 48 1
Gambia 167 115 58 3.8 63 54 82 39 49 40 26 36 13 5 2 46 1
Georgia 48 37 10 7.3 11 9 41 9 25 23 6 7 2 1 0 59 0
Germany 9 5 4 2.1 4 3 7 3 3 3 2 2 1 3 2 60 1
Ghana 127 99 48 4.1 52 43 80 35 42 36 24 27 12 41 21 51 9
Greece 10 6 4 2.0 5 4 9 4 6 4 3 2 1 0 0 56 0
Grenada 22 16 15 0.1 17 14 18 14 12 7 10 3 5 0 0 64 0
Guatemala 80 52 26 3.8 29 23 59 22 28 21 12 12 4 11 5 47 2
Guinea 236 166 101 2.8 105 96 139 65 62 47 31 49 21 44 14 32 8
Guinea-Bissau 223 175 81 4.2 88 75 132 54 64 55 37 40 16 5 2 46 1
Guyana 60 47 30 2.4 34 26 47 25 31 27 18 6 5 0 0 60 0
Haiti 144 103 65 2.6 70 59 100 49 39 30 26 31 12 17 7 40 3
Holy See − − − − − − − − − − − − − − − − −
Honduras 58 37 18 4.1 19 16 45 15 22 18 10 9 5 4 2 55 1
Hungary 17 10 4 4.8 5 4 15 4 11 6 2 3 1 0 0 53 0
Iceland 6 4 2 4.0 2 2 5 2 3 2 1 2 1 0 0 50 0
India 126 92 37 5.1 36 37 89 30 57 45 23 21 6 882 549 62 143
Indonesia 84 52 25 4.1 28 22 62 21 31 23 13 15 6 121 62 51 28
Iran (Islamic Republic of) 56 34 14 4.8 15 14 44 12 26 19 9 8 3 22 14 62 3
Iraq 54 44 27 2.8 29 24 42 22 26 24 15 9 7 29 17 58 7
Ireland 9 7 4 3.7 4 3 8 3 5 4 2 2 1 0 0 61 0
Israel 12 7 4 3.4 4 3 10 3 6 4 2 2 1 1 0 52 0
Italy 10 6 3 3.4 3 3 8 3 6 3 2 2 1 1 1 64 0
Jamaica 30 22 14 2.4 16 13 25 12 20 17 10 5 3 1 0 71 0
Japan 6 5 2 3.3 3 2 5 2 3 2 1 2 1 2 1 33 1
Jordan 36 27 16 2.9 18 15 30 14 20 16 9 5 3 3 2 59 1
Kazakhstan 52 43 10 8.1 11 9 44 9 22 21 6 6 3 4 2 56 1
Kenya 107 106 41 5.3 45 37 68 31 28 28 20 18 10 60 29 48 14
Kiribati 95 71 53 1.7 57 48 69 41 36 29 23 16 9 0 0 44 0
Kuwait 18 12 8 2.5 9 7 15 7 10 7 4 5 2 0 0 56 0
Kyrgyzstan 65 49 19 5.3 21 17 54 17 24 20 13 6 3 3 2 69 0
Lao People's Democratic Republic 153 107 47 4.5 52 42 105 38 47 38 23 44 9 8 4 48 1
Latvia 17 14 4 7.2 4 4 13 3 8 7 2 6 1 0 0 51 0
Lebanon 32 20 7 5.5 8 7 27 6 20 12 4 8 2 1 1 59 0
Lesotho 90 118 81 2.1 88 74 72 66 39 40 35 17 9 5 2 43 0
Liberia 262 187 71 5.4 76 65 175 53 59 45 24 33 17 11 4 35 2
Libya 42 28 12 4.8 13 11 35 10 21 15 6 8 6 2 1 52 1
Liechtenstein − − − − − − − − − − − − − − − − −
Lithuania 15 11 4 5.4 4 4 12 3 8 5 2 4 1 0 0 50 0
Luxembourg 9 5 2 3.8 3 2 7 2 4 2 1 2 0 0 0 60 0
Madagascar 159 107 54 3.9 58 49 97 38 39 31 21 41 12 45 18 39 8
Malawi 239 173 50 6.9 54 45 139 35 50 40 22 40 14 30 14 46 7
Malaysia 17 10 8 1.5 8 7 14 7 8 5 4 5 3 4 2 55 1
Maldives 86 39 9 8.4 9 8 63 7 39 22 5 12 2 0 0 55 0
Mali 230 188 98 3.6 103 92 120 62 67 51 33 44 26 75 26 34 15
Malta 11 8 7 0.4 8 6 10 6 8 5 5 2 1 0 0 67 0
Marshall Islands 49 41 33 1.1 37 29 39 27 20 18 15 9 6 0 0 46 0
Mauritania 117 114 76 2.3 81 70 71 52 46 43 33 21 8 11 5 45 1
Mauritius 23 19 16 1.0 17 14 20 14 15 12 9 4 2 0 0 59 0
Mexico 45 26 13 4.0 14 11 36 11 22 13 8 5 2 28 17 59 6
Micronesia (Federated States of) 55 54 31 3.1 34 27 43 26 26 25 16 10 6 0 0 53 0
Monaco 8 5 3 2.6 4 3 6 3 4 3 2 2 1 0 0 50 0
Mongolia 108 64 16 7.6 19 13 77 14 30 24 9 10 4 1 1 53 0
Montenegro 17 14 3 9.5 3 2 15 2 11 9 2 2 1 0 0 63 0
Montserrat − − − − − − − − − − − − − − − − −
Morocco 79 49 22 4.4 25 20 62 19 36 27 14 10 3 15 9 61 2
Mozambique 241 171 73 4.7 78 68 161 54 60 46 28 60 17 79 31 39 14
Myanmar 115 89 46 3.6 51 42 82 37 48 37 23 31 5 43 22 50 5
Namibia 74 77 40 3.7 43 36 50 29 28 23 16 16 12 3 1 40 1
Nauru 60 42 32 1.5 35 29 46 26 29 25 20 11 6 0 0 60 0
Nepal 140 81 32 5.1 34 30 97 27 58 40 20 29 6 18 11 62 3
Netherlands 8 6 4 2.6 4 3 7 3 5 4 2 2 1 1 0 55 0
New Zealand 11 7 6 1.4 6 5 9 5 4 3 3 3 1 0 0 61 0
 19 8 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 2. CHILD MORTALITY

Annual Under-5 Probability of dying Neonatal Number of

rate of mortality rate by among children Annual Annual deaths as deaths
Under-5 mortality rate reduction sex (deaths per Infant mortality Neonatal mortality rate aged 5–14 (deaths number of number of proportion of among
(deaths per 1,000 live in under-5 1,000 live births) rate (deaths per (deaths per 1,000 live per 1,000 children under-5 neonatal all under-5 children
Countries births) mortality
rate (%)
2018 1,000 live births) births) aged 5) deaths deaths
(thousands) (thousands)
deaths
(%)
aged 5–14
(thousands)
and areas 1990 2000 2018 2000–2018 male female 1990 2018 1990 2000 2018 1990 2018 2018 2018 2018 2018

Nicaragua 66 37 18 3.8 20 16 51 16 23 16 9 8 4 2 1 51 1
Niger 329 226 84 5.5 87 80 133 48 54 43 25 68 37 83 26 32 26
Nigeria 211 185 120 2.4 127 113 125 76 50 48 36 41 20 866 267 31 110
Niue 13 24 24 0.0 26 21 12 20 7 13 12 4 5 0 0 0 0
North Macedonia 36 16 10 2.6 11 9 33 9 17 9 7 3 1 0 0 74 0
Norway 9 5 3 3.6 3 2 7 2 4 3 1 2 1 0 0 59 0
Oman 39 16 11 2.0 12 10 32 10 17 7 5 6 2 1 0 45 0
Pakistan 139 112 69 2.7 74 65 106 57 65 60 42 14 10 409 251 62 46
Palau 35 29 18 2.6 20 16 30 17 19 15 9 7 4 0 0 50 0
Panama 31 26 15 2.9 17 14 26 13 17 15 8 8 3 1 1 56 0
Papua New Guinea 87 72 48 2.3 52 44 64 38 31 29 22 15 9 11 5 47 2
Paraguay 45 34 20 2.9 22 18 36 17 22 18 11 7 3 3 2 53 0
Peru 81 39 14 5.5 16 13 57 11 28 16 7 11 3 8 4 52 2
Philippines 57 38 28 1.6 31 25 40 22 19 17 14 14 5 63 30 47 12
Poland 17 9 4 4.1 5 4 15 4 11 6 3 3 1 2 1 61 0
Portugal 15 7 4 3.6 4 3 12 3 7 3 2 4 1 0 0 54 0
Qatar 21 12 7 3.3 7 6 18 6 11 7 4 4 1 0 0 53 0
Republic of Korea 15 7 3 4.7 3 3 13 3 7 3 1 5 1 1 1 46 0
Republic of Moldova 33 31 16 3.8 18 14 28 14 19 21 12 5 2 1 0 74 0
Romania 31 22 7 6.1 8 7 24 6 15 10 3 5 2 1 1 46 0
Russian Federation 22 19 7 5.5 8 6 18 6 11 10 3 5 2 13 6 44 4
Rwanda 154 183 35 9.1 38 32 94 27 40 41 16 72 10 13 6 46 3
Saint Kitts and Nevis 31 23 12 3.7 13 11 25 10 19 15 8 5 2 0 0 63 0
Saint Lucia 22 18 17 0.4 18 15 19 15 12 11 12 4 2 0 0 75 0
Saint Vincent and the Grenadines 24 23 16 1.8 18 15 20 15 13 13 10 4 5 0 0 58 0
Samoa 30 21 16 1.6 17 14 25 14 16 11 8 6 4 0 0 53 0
San Marino 13 6 2 6.3 2 2 12 2 7 3 1 2 1 0 0 − 0
Sao Tome and Principe 108 85 31 5.5 34 28 69 24 26 23 14 20 8 0 0 45 0
Saudi Arabia 45 22 7 6.4 7 7 36 6 22 12 4 7 2 4 2 53 1
Senegal 139 131 44 6.1 48 39 71 32 40 38 21 37 13 23 11 48 6
Serbia 28 13 6 4.6 6 5 24 5 17 8 3 3 1 0 0 61 0
Seychelles 17 14 14 -0.3 16 13 14 12 11 9 9 4 3 0 0 61 0
Sierra Leone 263 234 105 4.4 111 99 156 78 53 51 33 53 21 26 8 32 4
Singapore 8 4 3 1.8 3 3 6 2 4 2 1 2 1 0 0 38 0
Slovakia 15 10 6 3.1 6 5 13 5 9 5 3 3 1 0 0 49 0
Slovenia 10 6 2 5.2 2 2 9 2 6 3 1 2 1 0 0 55 0
Solomon Islands 39 30 20 2.3 22 18 31 17 15 13 8 8 4 0 0 42 0
Somalia 179 172 122 1.9 127 115 108 77 45 44 38 38 24 73 24 32 11
South Africa 59 74 34 4.3 37 31 46 28 20 17 11 8 6 40 13 32 6
South Sudan 254 183 99 3.4 103 93 150 64 65 57 40 52 20 38 15 41 6
Spain 9 5 3 3.2 3 3 7 3 5 3 2 2 1 1 1 56 0
Sri Lanka 22 17 7 4.4 8 7 19 6 13 10 4 6 2 3 2 60 1
State of Palestine 44 30 20 2.2 22 18 36 17 22 16 11 6 3 3 2 54 0
Sudan 132 104 60 3.0 65 55 82 42 43 37 29 29 8 80 38 48 9
Suriname 48 34 19 3.3 21 17 41 17 23 18 10 7 3 0 0 53 0
Sweden 7 4 3 2.3 3 2 6 2 4 2 2 1 1 0 0 56 0
Switzerland 8 6 4 1.7 4 4 7 4 4 3 3 2 1 0 0 72 0
Syrian Arab Republic 37 23 17 1.9 17 15 30 14 17 12 9 9 12 7 4 51 4
Tajikistan 102 84 35 4.9 39 31 81 30 31 28 15 12 5 10 4 44 1
Thailand 37 22 9 4.9 10 8 30 8 20 12 5 9 5 7 4 55 4
Timor-Leste 174 108 46 4.8 50 42 131 39 55 37 20 27 8 2 1 45 0
Togo 145 120 70 3.0 75 64 90 47 43 36 25 37 21 18 6 36 4
Tokelau − − − − − − − − − − − − − − − − −
Tonga 22 18 16 0.6 14 17 19 13 10 8 7 5 3 0 0 40 0
Trinidad and Tobago 30 29 18 2.5 20 17 27 16 20 18 12 4 2 0 0 63 0
Tunisia 55 30 17 3.2 18 15 43 15 29 20 11 7 3 3 2 67 1
Turkey 74 38 11 7.1 11 10 55 9 33 19 5 9 2 14 7 52 3
Turkmenistan 85 81 46 3.2 52 40 68 39 28 30 21 7 4 6 3 46 0
Turks and Caicos Islands − − − − − − − − − − − − − − − − −
Tuvalu 53 41 24 2.9 27 22 42 21 28 25 16 10 5 0 0 71 0
Uganda 185 148 46 6.4 51 42 109 34 39 32 20 32 15 74 32 44 19
Ukraine 19 18 9 4.1 10 8 17 7 12 11 5 4 2 4 2 58 1
United Arab Emirates 17 11 8 2.2 8 7 14 6 8 6 4 5 2 1 0 53 0
United Kingdom 9 7 4 2.4 5 4 8 4 4 4 3 2 1 3 2 60 1
 S TAT I S T I C A L TA B L E S » 19 9

TABLE 2. CHILD MORTALITY

Annual Under-5 Probability of dying Neonatal Number of

rate of mortality rate by among children Annual Annual deaths as deaths
Under-5 mortality rate reduction sex (deaths per Infant mortality Neonatal mortality rate aged 5–14 (deaths number of number of proportion of among
(deaths per 1,000 live in under-5 1,000 live births) rate (deaths per (deaths per 1,000 live per 1,000 children under-5 neonatal all under-5 children
Countries births) mortality
rate (%)
2018 1,000 live births) births) aged 5) deaths deaths
(thousands) (thousands)
deaths
(%)
aged 5–14
(thousands)
and areas 1990 2000 2018 2000–2018 male female 1990 2018 1990 2000 2018 1990 2018 2018 2018 2018 2018

United Republic of Tanzania 166 130 53 5.0 57 49 101 38 40 34 21 30 13 107 44 41 20

United States 11 8 7 1.4 7 6 9 6 6 5 4 2 1 25 14 54 6
Uruguay 23 17 8 4.5 8 7 20 6 12 8 5 3 2 0 0 60 0
Uzbekistan 72 63 21 6.0 24 18 60 19 31 29 12 6 3 15 8 54 2
Vanuatu 36 29 26 0.5 28 24 29 22 17 13 12 7 5 0 0 44 0
Venezuela (Bolivarian Republic of) 30 22 25 -0.7 26 23 25 21 13 11 15 4 3 13 8 61 2
Viet Nam 51 30 21 2.0 24 17 37 16 24 15 11 12 3 33 17 51 4
Yemen 126 95 55 3.0 59 51 88 43 43 37 27 20 8 47 23 50 6
Zambia 186 162 58 5.7 63 53 111 40 37 35 23 30 12 36 15 42 6
Zimbabwe 80 105 46 4.5 51 42 52 34 24 23 21 14 13 21 9 45 5

SUMMARY
East Asia and Pacific 57 40 15 5.4 16 14 43 12 27 20 8 10 3 462 230 50 103
Europe and Central Asia 31 21 9 5.0 10 8 25 8 14 10 5 4 2 96 50 52 17
Eastern Europe and Central
46 36 13 5.7 14 11 37 11 21 17 6 6 2 78 39 51 13
Asia
Western Europe 10 6 4 2.8 4 3 9 3 6 3 2 2 1 18 11 60 4
Latin America and Caribbean 55 33 16 3.8 18 15 43 14 23 16 9 6 3 172 95 55 30
Middle East and North Africa 65 42 22 3.7 23 20 50 18 28 21 12 10 4 220 122 56 37
North America 11 8 6 1.4 7 6 9 5 6 5 3 2 1 27 15 55 6
South Asia 130 94 42 4.5 43 41 92 35 59 47 26 20 6 1,475 909 62 211
Sub-Saharan Africa 180 153 78 3.8 83 72 107 53 46 41 28 40 18 2,869 1,054 37 518
Eastern and Southern Africa 164 136 57 4.8 62 52 101 40 43 38 24 39 13 1,024 441 43 189
West and Central Africa 197 170 97 3.1 103 90 115 64 48 44 31 40 23 1,845 613 33 330
Least developed countries 175 137 64 4.2 69 59 108 46 52 42 26 39 14 1,992 821 41 371
World 93 76 39 3.8 41 36 65 29 37 31 18 15 7 5,322 2,476 47 923
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES

Under-5 mortality rate – Probability of dying between birth Under-5, infant, neonatal and age Under-5 deaths, neonatal deaths and
and exactly 5 years of age, expressed per 1,000 live births. 5–14 mortality rates – United Nations deaths aged 5–14 – United Nations
Infant mortality rate – Probability of dying between birth and Inter-agency Group for Child Mortality Inter-agency Group for Child Mortality
exactly 1 year of age, expressed per 1,000 live births. Estimation (UNICEF, World Health Estimation (UNICEF, World Health
Organization, United Nations Population Organization, United Nations Population
Neonatal mortality rate – Probability of dying during the first Division and the World Bank Group). Last Division and the World Bank Group). Last
28 days of life, expressed per 1,000 live births. update: September 2019. update: September 2019.
Probability of dying among children aged 5–14 –
Probability of dying at age 5–14 years expressed per 1,000
children aged 5. NOTES
– Data not available.
 200 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 3. MATERNAL AND NEWBORN HEALTH

Demand for
family planning
satisfied with
modern methods Postnatal health
(%) Antenatal care (%) Delivery care (%) check(%)+ Maternal mortality†
2013–2018* 2013–2018* 2013–2018* 2013–2018* 2017

Skilled birth
Life Adoles- Births by At least four visits attendant Lifetime
expec- cent birth age 18 risk of
Countries tancy: Women Women
female aged aged
rate
2013–
(%)
2013–
At least Women Women
one aged aged
Women
aged
Women
aged
Institu-
tional C-
For
new- For
Number of Maternal maternal
maternal mortality death (1
and areas 2018 15–49 15–19 2018* 2018* visit 15–49 15–19 15–49 15–19 delivery section borns mothers deaths ratio in X)

Afghanistan 66 42 21 77 20 59 18 16 51 54 48 3 9 40 7,700 638 33

Albania 80 5 5 17 3 88 78 72 100 100 99 31 86 88 5 15 3,800
Algeria 78 77 – 10 1 93 67 – 97 – 97 16 – – 1,200 112 270
Andorra – – – 3 – – – – – – – – – – – – –
Angola 64 24 15 163 38 82 61 56 50 50 46 4 21 23 3,000 241 69
Anguilla – – – 40 x – – – – – – – – – – – – –
Antigua and Barbuda 78 – – 67 x – 100 x 100 – 100 – – – – – 1 42 1,200
Argentina 80 – – 65 12 x 98 x 90 x 85 x 100 – 99 29 x – – 290 39 1,100
Armenia 78 37 – 24 1 100 96 93 100 100 99 18 98 97 11 26 2,000
Australia 85 – – 10 – 98 x 92 x – – – 99 31 x – – 20 6 8,200
Austria 84 – – 7 – – – – 99 – 99 24 x – – 4 5 13,500
Azerbaijan 75 21 x 13 x 53 4 x 92 x 66 x 40 x 100 93 x 93 x 20 x – 83 x 44 26 1,700
Bahamas 76 – – 32 x – 98 x 85 – 98 – – – – – 4 70 820
Bahrain 78 – – 14 – 100 x 100 – 100 – 98 x – – – 3 14 3,000
Bangladesh 74 73 68 78 36 64 31 32 42 42 37 23 32 36 5,100 173 250
Barbados 80 70 x – 50 x 7 x 93 x 88 x – 99 – 100 x 21 x 98 x 97 x 1 27 2,400
Belarus 79 74 x – 16 3 x 100 x 100 x 95 x 100 100 x 100 x 25 x 100 x 100 x 3 2 23,800
Belgium 84 – – 6 – – – – – – – 18 x – – 6 5 11,200
Belize 78 66 47 64 17 97 93 92 97 97 96 34 96 96 3 36 1,100
Benin 63 26 13 94 19 83 52 52 78 77 84 5 64 66 1,600 397 49
Bhutan 72 85 x – 28 x 15 x 98 x 85 66 x 75 x 40 x 74 x 12 x 30 x 41 x 24 183 250
Bolivia (Plurinational State of) 74 50 – 71 20 x 96 86 69 x 85 x 76 x 88 33 – – 380 155 220
Bosnia and Herzegovina 80 22 x – 11 – 87 x 84 x – 100 – 100 x 14 x – – 3 10 8,200
Botswana 72 – – 50 – 94 x 73 x – 99 x – 100 – – – 81 144 220
Brazil 79 89 x – 59 – 97 91 – 99 – 99 56 – – 1,700 60 940
British Virgin Islands – – – 27 x – – – – – – – – – – – – –
Brunei Darussalam 77 – – 11 – 99 x 93 x – 100 – 100 x – – – 2 31 1,700
Bulgaria 79 – – 38 5 – – – 100 – 94 36 – – 6 10 7,000
Burkina Faso 62 55 51 132 28 x 93 47 32 x 80 75 x 82 4 33 74 2,400 320 57
Burundi 63 37 55 58 13 99 49 52 85 91 84 4 x 8 x 51 2,400 548 33
Cabo Verde 76 73 x 68 x 80 x 22 x 98 x 72 x – 92 – 76 x 11 x – – 6 58 670
Cambodia 72 56 46 57 7 95 76 71 89 91 83 6 79 90 590 160 220
Cameroon 60 38 39 119 28 83 59 51 65 66 61 2 69 65 4,700 529 40
Canada 84 – – 8 – 100 x 99 x – 100 x – 98 x 26 x – – 40 10 6,100
Central African Republic 55 29 x – 229 x 45 x 68 x 38 x 32 x 40 x 46 x 53 x 5 x – – 1,400 829 25
Chad 55 18 9 179 51 55 31 33 20 27 22 1 5 16 7,300 1,140 15
Chile 82 – – 33 – – – – 100 – 100 50 x – – 29 13 4,600
China 79 97 x – 9 – 100 81 – 100 – 100 41 63 64 4,900 29 2,100
Colombia 80 86 72 75 20 97 90 86 99 96 99 46 7 x 1 610 83 630
Comoros 66 27 x 20 x 70 x 17 x 92 x 49 x 38 x 82 x 82 x 76 x 10 x 14 x 49 x 72 273 83
Congo 66 39 28 111 26 94 79 77 94 92 92 5 86 80 650 378 58
Cook Islands – – – 67 – 100 x – – 100 x – 100 x – – – – – –
Costa Rica 83 89 x – 53 13 98 x 90 x 88 x 99 98 x 99 22 – – 19 27 1,900
Côte d'Ivoire 59 39 – 123 25 93 51 47 74 76 70 3 83 80 5,400 617 34
Croatia 81 – – 10 – – 98 – 100 – – 24 – – 3 8 9,100
Cuba 81 88 73 52 6 99 98 99 99 97 100 40 98 99 42 36 1,800
Cyprus 83 – – 4 – 99 x – – – – 97 – – – 1 6 11,000
Czechia 82 – – 12 – – – – 100 x – 100 20 x – – 4 3 17,900
Democratic People's Republic of
76 90 – 1 – 100 94 – 100 – 92 13 99 98 310 89 620
Korea
Democratic Republic of the Congo 62 16 12 138 x 27 88 48 50 80 81 80 5 8 44 16,000 473 34
Denmark 83 – – 3 – – – – – – – 21 x – – 2 4 16,200
Djibouti 69 – – 21 x – 88 x 23 x – 87 x – 87 x 11 x – – 51 248 140
Dominica – – – 48 x – 100 x – – 100 – – – – – – – –
Dominican Republic 77 84 67 90 21 98 93 90 98 99 98 58 95 95 200 95 410
Ecuador 80 80 x – 111 x – 84 x 58 x – 96 – 93 46 – – 200 59 640
Egypt 74 80 64 56 7 90 83 88 92 93 87 52 14 82 960 37 730
El Salvador 78 82 70 69 x 18 96 90 90 98 99 98 32 97 94 54 46 960
Equatorial Guinea 60 21 x 20 x 176 x 42 x 91 x 67 x – 68 x – 67 x 7 x – – 130 301 67
Eritrea 68 20 x 6 x 76 x 19 x 89 x 57 x – 34 x – 34 x 3 x – 5 x 510 480 46
Estonia 83 – – 11 – – 97 – 100 x – 99 – – – 1 9 6,900
Eswatini 64 81 – 87 17 99 76 68 88 89 88 12 90 88 130 437 72
Ethiopia 68 62 – 80 21 62 32 30 28 39 26 2 0 x 17 14,000 401 55
 S TAT I S T I C A L TA B L E S » 2 01

TABLE 3. MATERNAL AND NEWBORN HEALTH

Demand for
family planning
satisfied with
modern methods Postnatal health
(%) Antenatal care (%) Delivery care (%) check(%)+ Maternal mortality†
2013–2018* 2013–2018* 2013–2018* 2013–2018* 2017

Skilled birth
Life Adoles- Births by At least four visits attendant Lifetime
expec- cent birth age 18 risk of
Countries tancy: Women Women
female aged aged
rate
2013–
(%)
2013–
At least Women Women
one aged aged
Women
aged
Women
aged
Institu-
tional C-
For
new- For
Number of Maternal maternal
maternal mortality death (1
and areas 2018 15–49 15–19 2018* 2018* visit 15–49 15–19 15–49 15–19 delivery section borns mothers deaths ratio in X)

Fiji 69 – – 40 – 100 x 94 – 100 – 99 – – – 6 34 1,000

Finland 85 – – 6 – 100 x – – – – 100 16 x – – 2 3 20,900
France 85 96 x – 5 – 100 x 99 x – – – 98 21 x – – 56 8 7,200
Gabon 68 34 x 23 x 91 x 28 x 95 x 78 x 76 x 89 x 91 x 90 x 10 x 25 x 60 x 170 252 93
Gambia 63 24 11 86 x 19 86 78 74 57 64 63 2 6 76 520 597 31
Georgia 78 – – 44 6 x 98 x 88 – 100 – 100 41 – – 14 25 1,900
Germany 84 – – 9 – 100 x 99 – – – 99 29 x – – 53 7 9,400
Ghana 65 46 – 75 17 91 87 81 71 76 73 13 23 81 2,700 308 82
Greece 85 – – 9 – – – – – – – – – – 2 3 26,900
Grenada 75 – – 36 – 100 x – – 99 – – – – – 0 25 1,700
Guatemala 77 65 50 92 20 91 86 85 66 70 65 26 8 78 400 95 330
Guinea 62 21 14 120 37 81 35 48 55 60 53 3 64 49 2,600 576 35
Guinea-Bissau 60 38 20 106 x 28 92 65 65 45 55 44 4 55 48 440 667 32
Guyana 73 52 17 74 16 91 87 86 86 94 93 17 95 93 26 169 220
Haiti 66 41 31 55 14 91 67 55 42 37 39 5 38 31 1,300 480 67
Holy See – – – – – – – – – – – – – – – – –
Honduras 77 76 x 67 x 103 22 x 97 x 89 x 87 x 83 x 87 x 83 x 19 x 81 x 85 x 130 65 560
Hungary 80 – – 25 – – – – 99 x – – 31 x – – 11 12 6,200
Iceland 84 – – 7 – – – – – – – 17 x – – 0 4 14,400
India 71 66 27 11 9 79 51 53 81 86 79 17 27 65 35,000 145 290
Indonesia 74 78 72 48 x 7 98 77 65 94 87 74 17 79 87 8,600 177 240
Iran (Islamic Republic of) 78 69 x – 36 5 x 97 x 94 x – 96 x – 95 x 46 x – – 250 16 2,600
Iraq 72 55 – 82 x 14 88 68 76 96 97 87 33 78 83 870 79 320
Ireland 84 – – 7 – 100 x – – 100 x – 100 25 x – – 3 5 11,300
Israel 84 – – 9 – – – – – – – – – – 5 3 10,800
Italy 85 – – 5 – 99 x 68 x – – – 100 40 x – – 7 2 51,300
Jamaica 76 79 x – 46 x 15 x 98 x 86 x 85 x 99 x 97 x 99 x 21 x – – 38 80 600
Japan 88 – – 4 – – – – – – 100 – – – 44 5 16,700
Jordan 76 57 31 27 5 98 92 93 100 100 98 26 86 83 100 46 730
Kazakhstan 77 82 – 25 2 99 95 98 99 99 99 15 99 98 37 10 3,500
Kenya 69 78 68 96 23 94 58 49 62 65 61 9 36 53 5,000 342 76
Kiribati 72 36 x 0 x 49 x 9 x 88 x 71 x – 98 x – 66 x 10 x – – 3 92 290
Kuwait 76 – – 6 – 100 x – – 99 x – 99 – – – 7 12 4,200
Kyrgyzstan 75 65 41 34 4 98 95 93 98 98 98 7 99 98 95 60 480
Lao People's Democratic Republic 69 61 x 48 x 83 18 78 62 52 64 56 65 6 47 47 310 185 180
Latvia 80 – – 15 – 92 x – – 100 x – 98 – – – 4 19 3,100
Lebanon 81 – – 17 x – 96 x – – 98 x – 100 x – – – 34 29 1,600
Lesotho 57 76 55 94 14 95 74 70 78 85 77 10 18 62 310 544 58
Liberia 65 37 22 150 37 96 78 78 61 67 56 4 35 77 1,000 661 32
Libya 76 24 – 11 – 93 x – – – – 100 – – – 92 72 590
Liechtenstein – – – 4 – – – – – – – – – – – – –
Lithuania 81 – – 13 – 100 x – – 100 x – – – – – 2 8 7,500
Luxembourg 84 – – 5 – – 97 x – 100 x – 100 x 29 x – – 0 5 14,300
Madagascar 68 60 – 152 36 82 51 47 x 44 40 x 38 2 – – 2,800 335 66
Malawi 67 75 62 138 31 98 51 46 90 92 91 6 60 42 2,100 349 60
Malaysia 78 – – 10 – 97 – – 99 – 99 – – – 150 29 1,600
Maldives 80 43 x 18 x 10 1 99 82 87 100 100 95 40 82 80 4 53 840
Mali 60 33 21 174 33 80 43 38 67 42 67 2 63 58 4,400 562 29
Malta 84 – – 13 – 100 x – – – – 100 – – – 0 6 10,200
Marshall Islands – 80 x 40 x 85 x 21 x 81 x 77 x – 90 x – 85 x 9 x – – – – –
Mauritania 66 30 – 84 22 87 63 56 69 67 69 5 58 57 1,100 766 28
Mauritius 78 41 – 24 – – – – 100 – 98 x – – – 8 61 1,200
Mexico 78 81 64 71 21 99 94 93 98 98 97 41 95 95 740 33 1,300
Micronesia (Federated States of) 69 – – 44 x – 80 x – – 100 x – 87 x 11 x – – 2 88 370
Monaco – – – – – – – – – – – – – – – – –
Mongolia 74 67 42 30 3 99 90 81 100 97 98 23 99 95 35 45 710
Montenegro 79 34 – 10 3 92 87 – 99 – 99 20 99 95 0 6 9,900
Montserrat – – – 54 x – – – – – – – – – – – – –
Morocco 78 69 – 32 x 8 x 89 54 30 x 87 x 70 x 86 21 – – 480 70 560
Mozambique 63 50 34 194 40 x 87 52 55 65 68 55 x 4 x 28 – 3,100 289 67
Myanmar 70 75 73 36 5 81 59 47 60 61 37 17 36 71 2,400 250 190
Namibia 66 75 47 64 15 97 63 58 88 88 87 14 20 69 140 195 140
Nauru – 42 x – 94 22 x 95 x 40 x – 97 x – 99 x 8 x – – – – –
 202 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 3. MATERNAL AND NEWBORN HEALTH

Demand for
family planning
satisfied with
modern methods Postnatal health
(%) Antenatal care (%) Delivery care (%) check(%)+ Maternal mortality†
2013–2018* 2013–2018* 2013–2018* 2013–2018* 2017

Skilled birth
Life Adoles- Births by At least four visits attendant Lifetime
expec- cent birth age 18 risk of
Countries tancy: Women Women
female aged aged
rate
2013–
(%)
2013–
At least Women Women
one aged aged
Women
aged
Women
aged
Institu-
tional C-
For
new- For
Number of Maternal maternal
maternal mortality death (1
and areas 2018 15–49 15–19 2018* 2018* visit 15–49 15–19 15–49 15–19 delivery section borns mothers deaths ratio in X)

Nepal 72 56 25 88 16 84 69 72 58 69 57 9 58 57 1,100 186 230

Netherlands 84 – – 3 – – – – – – – 14 x – – 9 5 11,900
New Zealand 84 – – 15 – – – – – – 97 23 x – – 5 9 6,100
Nicaragua 78 93 x 87 x 92 x 28 x 95 x 88 x – 88 x – 71 30 x – – 130 98 380
Niger 63 45 28 146 48 x 83 x 38 32 x 40 36 x 59 1 x 13 x 37 x 5,100 509 27
Nigeria 55 38 15 120 31 67 57 47 43 32 39 3 12 42 67,000 917 21
Niue – – – 20 x – 100 x – – 100 x – – – – – – – –
North Macedonia 78 22 x – 16 2 x 99 x 94 x – 100 – 100 25 x – – 2 7 9,000
Norway 84 – – 4 – – – – – – 99 16 x – – 1 2 25,700
Oman 80 40 – 14 2 99 94 – 99 – 99 19 98 95 17 19 1,600
Pakistan 68 49 23 46 7 86 51 44 69 70 66 22 64 62 8,300 140 180
Palau – – – 27 – 90 x 81 x – 100 – 100 x – – – – – –
Panama 82 74 37 79 – 93 88 84 94 89 91 28 93 92 41 52 750
Papua New Guinea 66 41 x – 65 x 14 x 76 49 – 53 x – 55 – – 46 340 145 190
Paraguay 76 83 83 72 – 99 94 92 96 97 93 46 8 94 180 129 290
Peru 79 67 65 44 16 97 96 93 92 90 91 32 96 61 500 88 480
Philippines 75 53 47 47 11 94 87 80 84 86 78 13 86 86 2,700 121 300
Poland 82 – – 12 – – – – 100 x – 100 21 x – – 8 2 30,300
Portugal 85 – – 8 – 100 x – – 100 x – 99 31 x – – 6 8 10,700
Qatar 82 69 x – 10 – 91 x 85 x – 100 – 99 x 20 x – – 2 9 5,000
Republic of Korea 86 – – 1 – – 97 x – – – 100 32 x – – 43 11 8,300
Republic of Moldova 76 60 x – 24 4 x 99 x 95 x – 100 – 99 x 16 x – – 8 19 3,900
Romania 79 – – 37 – 76 76 x – 95 – 95 34 – – 36 19 3,600
Russian Federation 78 – – 24 – – – – 100 x – 99 x 13 x – – 320 17 3,100
Rwanda 71 65 84 41 6 98 44 39 91 94 91 13 19 43 960 248 94
Saint Kitts and Nevis – – – 46 x – 100 x – – 100 – – – – – – – –
Saint Lucia 77 72 x – 43 x – 97 x 90 x – 99 x – 100 x 19 x 100 x 90 x 3 117 580
Saint Vincent and the Grenadines 75 – – 64 – 100 x 100 x – 99 – – – – – 1 68 750
Samoa 75 39 11 39 x 6 93 73 – 83 – 82 5 – 63 2 43 590
San Marino – – – 0 x – – – – – – – – – – – – –
Sao Tome and Principe 73 51 38 92 27 98 84 81 93 94 91 6 91 87 9 130 170
Saudi Arabia 77 – – 7 x – 97 x – – 98 – – – – – 100 17 2,300
Senegal 70 50 25 78 16 97 57 53 68 69 78 5 78 77 1,700 315 65
Serbia 78 25 – 15 1 98 94 95 98 98 98 29 – – 10 12 5,800
Seychelles 77 – – 66 – – – – 99 x – – – – – 1 53 790
Sierra Leone 55 45 32 101 30 97 78 77 82 82 77 3 92 90 2,900 1,120 20
Singapore 86 – – 3 – – – – – – 100 – – – 4 8 9,900
Slovakia 81 – – 26 – 97 x – – 99 x – – 24 x – – 3 5 12,600
Slovenia 84 – – 4 – 100 x – – 100 x – 100 x – – – 1 7 9,300
Solomon Islands 75 38 13 78 15 89 69 – 86 – 85 6 16 69 22 104 200
Somalia 59 – – 123 x – 26 x 6 x – 9 x – 9 x – – – 5,100 829 20
South Africa 67 73 – 71 15 x 94 76 77 97 97 96 26 – 84 1,400 119 330
South Sudan 59 6 x – 158 x 28 x 62 17 x 21 x 19 x 25 x 12 x 1 x – – 4,500 1,150 18
Spain 86 – – 8 – – – – – – – 26 x – – 14 4 21,500
Sri Lanka 80 74 58 21 4 x 99 93 x – 100 – 100 32 – 99 120 36 1,300
State of Palestine 76 65 35 48 22 99 96 96 100 100 99 20 94 91 39 27 880
Sudan 67 30 19 87 22 79 51 49 78 77 28 9 28 27 3,900 295 75
Suriname 75 73 x – 60 – 91 x 67 x 68 x 90 x 93 x 92 x 19 x – – 13 120 330
Sweden 84 – – 4 – 100 x – – – – – – – – 5 4 12,600
Switzerland 85 – – 3 – – – – – – – 30 x – – 4 5 13,900
Syrian Arab Republic 78 53 x 31 x 54 x 9 x 88 x 64 x – 96 x – 78 x 26 x – – 130 31 1,000
Tajikistan 73 45 18 54 1 92 64 67 95 96 88 5 90 92 46 17 1,400
Thailand 81 89 83 43 9 98 91 89 99 99 99 33 – – 270 37 1,900
Timor-Leste 71 38 22 42 7 84 77 74 56 58 49 4 31 35 52 142 170
Togo 62 32 15 89 8 52 57 52 45 58 73 7 35 71 1,000 396 56
Tokelau – – – 30 x – – – – – – – – – – – – –
Tonga 73 48 x – 30 x 2 x 99 x 70 x – 96 x – 98 x 17 x – – 1 52 540
Trinidad and Tobago 76 58 x 61 x 38 x – 95 x 100 – 100 – 98 x 22 x – 92 x 12 67 840
Tunisia 79 73 x – 7 x 1 x 98 x 85 x – 74 x – 99 x 27 x 98 x 92 x 90 43 970
Turkey 80 60 30 23 6 97 89 57 x 97 98 97 48 72 88 220 17 2,800
Turkmenistan 72 76 11 28 1 100 96 98 100 100 100 6 100 100 10 7 4,400
Turks and Caicos Islands – – – 41 x – – – – – – – – – – – – –
 S TAT I S T I C A L TA B L E S » 2 0 3

TABLE 3. MATERNAL AND NEWBORN HEALTH

Demand for
family planning
satisfied with
modern methods Postnatal health
(%) Antenatal care (%) Delivery care (%) check(%)+ Maternal mortality†
2013–2018* 2013–2018* 2013–2018* 2013–2018* 2017

Skilled birth
Life Adoles- Births by At least four visits attendant Lifetime
expec- cent birth age 18 risk of
Countries tancy: Women Women
female aged aged
rate
2013–
(%)
2013–
At least Women Women
one aged aged
Women
aged
Women
aged
Institu-
tional C-
For
new- For
Number of Maternal maternal
maternal mortality death (1
and areas 2018 15–49 15–19 2018* 2018* visit 15–49 15–19 15–49 15–19 delivery section borns mothers deaths ratio in X)

Tuvalu – 41 x – 28 x 3 x 97 x 67 x – 93 x – 93 x 7 x – – – – –
Uganda 65 54 – 132 28 97 60 59 74 80 73 5 x 11 x 54 6,000 375 49
Ukraine 77 68 x – 23 4 x 99 x 87 x 87 x 99 x 99 x 99 x 12 x 99 x 96 x 83 19 3,700
United Arab Emirates 79 – – 5 – 100 x – – 100 x – 100 x – – – 3 3 17,900
United Kingdom 83 – – 14 – – – – – – – 26 x – – 52 7 8,400
United Republic of Tanzania 67 52 35 139 22 98 62 48 64 70 63 6 42 34 11,000 524 36
United States 81 – – 19 – – 97 x – 99 – – 31 x – – 720 19 3,000
Uruguay 81 – – 36 – 97 77 44 x 100 100 x 100 30 – – 8 17 2,900
Uzbekistan 74 – – 30 x 2 x 99 – – 100 – 100 14 – – 200 29 1,200
Vanuatu 72 51 – 78 x 13 76 52 – 89 – 89 12 – – 6 72 330
Venezuela (Bolivarian Republic of) 76 – – 95 x 24 98 84 – 100 – 99 52 – – 670 125 330
Viet Nam 79 69 60 30 5 96 74 55 94 87 94 28 89 90 700 43 1,100
Yemen 68 38 22 67 x 17 60 25 30 45 52 30 5 11 20 1,400 164 150
Zambia 66 64 57 141 x 31 96 56 52 63 73 67 4 16 63 1,300 213 93
Zimbabwe 63 85 77 78 22 93 76 73 78 81 77 6 73 57 2,100 458 55

SUMMARY
East Asia and Pacific 79 – – 16 – 97 80 – 96 – 91 32 69 72 21,000 69 790
Europe and Central Asia 81 – – 17 – – – – 99 – 98 – – – – – –
Eastern Europe and Central
78 – – 26 – 96 – – 99 – 97 28 – – 1,200 19 2,600
Asia
Western Europe 84 – – 9 – – – – 99 – 99 – – – 260 5 11,700
Latin America and Caribbean 79 – – 65 – 97 91 – 94 – 94 44 – – 7,800 74 630
Middle East and North Africa 76 67 – 38 9 87 68 – 89 – 82 32 – – 5,800 57 570
North America 82 – – 18 – – – – 99 – – – – – 760 18 3,100
South Asia 71 64 30 25 12 79 49 49 77 78 72 18 34 62 57,000 163 240
Sub-Saharan Africa 63 47 29 114 26 81 53 50 59 61 57 5 30 46 200,000 533 38
Eastern and Southern Africa 66 59 45 108 25 85 53 49 62 67 56 7 34 40 70,000 384 58
West and Central Africa 59 35 19 121 28 78 54 51 57 54 58 4 28 52 131,000 674 28
Least developed countries 72 52 38 94 25 80 47 44 61 60 54 7 31 42 130,000 415 56
World 75 63 38 43 15 86 65 56 81 76 76 21 45 61 295,000 211 190
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES NOTES

Life expectancy at birth – Number of years
newborn female children would live if subject to
the mortality risks prevailing for the cross section
of population at the time of their birth.
Demand for family planning satisfied with
modern methods – Percentage of married/in
union women (15-19 and 15-49) who have their
need for family planning satisfied with modern
methods.
Adolescent birth rate – Number of births per
1,000 adolescent girls aged 15-19.
Births by age 18 – Percentage of women aged
20-24 who gave birth before age 18. The indicator
refers to women who had a live birth in a recent
time period, generally two years for MICS and five
years for DHS.
Antenatal care (at least one visit) –
Percentage of women (aged 15–49) attended at
least once during pregnancy by skilled health
personnel (typically a doctor, nurse or midwife).
Antenatal care (at least four visits) –
Percentage of women (aged 15-19 and 15-49)
attended by any provider at least four times.
Skilled birth attendant – Percentage of births
from mothers aged 15-19 and 15-49, attended by
skilled heath personnel (typically a doctor, nurse or
midwife).
Institutional delivery – Percentage of women
(aged 15–49) who gave birth in a health facility.
C-section – Percentage of births delivered by
Caesarean section. NB: C-section rates between 5
per cent and 15 per cent are expected with
adequate levels of emergency obstetric care.
Postnatal health check for newborn –
Percentage of last live births in the last 2 years
who received a health check within 2 days after
delivery. NB: For MICS, health check refers to a
health check while in facility or at home following
delivery or a postnatal visit.
Postnatal health check for mother –
Percentage of women (aged 15–49) who received
a health check within 2 days after delivery of their
most recent live birth in the last 2 years. NB: For
MICS, health check refers to a health check while
in facility or at home following delivery or a
postnatal visit.
Number of maternal deaths – Number of
deaths of women from pregnancy-related causes.
Maternal mortality ratio – Number of deaths of
women from pregnancy-related causes per
100,000 live births during the same time period.
Lifetime risk of maternal death – Lifetime risk
of maternal death takes into account both the
probability of becoming pregnant and the
probability of dying as a result of that pregnancy,
accumulated across a woman’s reproductive
years.
Life expectancy – United Nations Population
Division, World Population Prospects 2019. Last
update: July 2019.
Demand for family planning satisfied with
modern methods – United Nations,
Department of Economic and Social Affairs,
Population Division (2019), based on
Demographic and Health Surveys (DHS),
Multiple Indicator Cluster Surveys (MICS),
Reproductive Health Surveys, other national
surveys, and National Health Information
Systems (HIS). Last Update: February 2019.
Adolescent birth rate – United Nations
Population Division, 2019. Last update: July
2019.
Births by age 18 – DHS, MICS and other
national household surveys. Last update: May
2019.
Antenatal care (at least one visit) – DHS,
MICS and other national household surveys.
Last update: May 2019.
Antenatal care, at least four visits (women
15-19) – International Center for Equity in
Health, Federal University of Pelotas, Brazil,
based on Demographic and Health Surveys
(DHS), Multiple Indicator Cluster Surveys (MICS)
and other national surveys. Last update: August
2019.
Skilled birth attendant – Joint UNICEF/WHO
SBA database, based on DHS, MICS and other
national household surveys as well as national
administrative data. Last update: February 2019.
Skilled birth attendant (women 15-19) –
International Center for Equity in Health, Federal
University of Pelotas, Brazil, based on
Demographic and Health Surveys (DHS),
Multiple Indicator Cluster Surveys (MICS) and
other national surveys. Last update: August
2019.
Institutional delivery – DHS, MICS and other
national household surveys. Last update: May
2019.
C-section – DHS, MICS and other national
household surveys. Last update: May 2019.
Postnatal health check for newborn and
mother – DHS, MICS and other national
household surveys. Last update: May 2019.
Number of maternal deaths – United Nations
Maternal Mortality Estimation Inter-agency
Group (WHO, UNICEF, UNFPA, the World Bank
and the United Nations Population Division).
Last Update: September 2019.
Maternal mortality ratio – United Nations
Maternal Mortality Estimation Inter-agency
Group (WHO, UNICEF, UNFPA, The World Bank
and the United Nations Population Division).
Last Update: September 2019.
Lifetime risk of maternal death – United
Nations Maternal Mortality Estimation
Inter-agency Group (WHO, UNICEF, UNFPA, the
World Bank and the United Nations Population
Division). Last Update: September 2019.
− Data not available.
x Data refer to years or periods other than
those specified in the column heading.
Such data are not included in the calcu-
lation of regional and global averages.
Estimates from data years prior to 2000
are not displayed.
+ Data collection method for this indicator
varies across surveys and may affect
comparability of the coverage estimates.
For detailed explanation see General
Note on the Data, page 180.
† Maternal mortality estimates are from
the 2019 United Nations inter-agency
maternal mortality estimates. Periodical-
ly, the United Nations Maternal Mortality
Estimation Inter-agency Group (WHO,
UNICEF, UNFPA, the World Bank and
the United Nations Population Division)
produces internationally comparable sets
of maternal mortality data that account
for the well-documented problems of
under-reporting and misclassification of
maternal deaths, including also estimates
for countries with no data. Please note
that owing to an evolving methodology,
these values are not comparable with
previously reported maternal mortality
ratio ‘adjusted’ values.
* Data refer to the most recent year
available during the period specified in
the column heading.
 204 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 4. CHILD HEALTH

Intervention coverage
Immunization for vaccine preventable diseases (%) Pneumonia Diarrhoea Malaria
2018β 2013–2018* 2013–2018* 2013–2018*
Care seeking for Treatment
Protection at children with with oral Care seeking Children
Countries birth (PAB)
against
symptoms of rehydration
Acute Respiratory salts (ORS)
for children
with fever
sleeping
under ITNs
Households
with at least
and areas BCG DTP1 DTP3 Polio3 MCV1 MCV2^ HepB3 Hib3 Rota PCV3 tetanusλ Infection (ARI)(%) (%) (%) (%) one ITN (%)

Afghanistan 78 73 66 73 64 39 66 66 60 65 68 62 46 63 5 26
Albania 99 99 99 99 94 96 99 99 – 98 95 82 35 60 − −
Algeria 99 96 91 91 80 77 91 91 – 91 98 66 25 − − −
Andorra – 99 99 99 99 95 98 99 – 94 – − − − − −
Angola 86 67 59 56 50 35 59 59 65 67 78 49 43 51 22 31
Anguilla – – – – – – – – – – – − − − − −
Antigua and Barbuda – 99 95 94 96 95 95 95 – – – − − − − −
Argentina 93 91 86 84 94 89 86 86 80 88 – 94 x 18 x − − −
Armenia 99 96 92 92 95 96 92 92 93 92 – 57 x 37 71 − −
Australia – 98 95 95 95 93 95 94 87 95 – − − − − −
Austria – 90 85 85 94 84 85 85 61 – – − − − − −
Azerbaijan 97 96 95 96 96 96 95 95 – 95 – 36 x 11 x − 1 x −
Bahamas – 94 90 90 89 69 90 90 70 90 100 − − − − −
Bahrain – 99 99 99 99 99 99 99 98 98 98 − − − − −
Bangladesh 99 99 98 98 97 93 98 98 – 97 98 42 77 55 − −
Barbados – 96 95 94 85 74 95 95 – 89 – − − − − −
Belarus 98 97 97 98 97 98 98 9 – – – 93 x 45 x − − −
Belgium – 99 98 98 96 85 97 97 87 94 – − − − − −
Belize 99 97 96 96 97 91 96 96 – – 91 67 55 71 − −
Benin 89 84 76 75 71 – 76 76 – 73 85 46 22 53 70 85
Bhutan 99 98 97 97 97 91 97 97 – – 89 74 x 61 x − − −
Bolivia (Plurinational State of) 90 89 83 83 89 38 83 83 87 83 87 62 x 22 x − − −
Bosnia and Herzegovina 95 89 73 73 68 76 80 62 – – – 87 x 36 x − − −
Botswana 98 98 95 96 97 74 95 95 87 91 93 14 x 43 x 75 x 31 x 53 x
Brazil 90 87 83 85 84 69 83 83 80 84 94 50 x − − − −
British Virgin Islands – – – – – – – – – – – − − − − −
Brunei Darussalam 99 99 99 99 99 98 99 99 – – 96 − − − − −
Bulgaria 96 94 92 92 93 87 85 92 31 88 – − − − − −
Burkina Faso 98 95 91 91 88 71 91 91 91 91 92 52 40 74 54 75
Burundi 91 94 90 90 88 77 90 90 92 90 90 63 36 70 40 46
Cabo Verde 96 99 98 98 99 88 99 99 – – 92 − − − − −
Cambodia 93 94 92 90 84 70 92 92 – 84 93 69 35 61 4 x 5 x
Cameroon 88 86 79 78 71 – 79 79 78 79 85 28 16 33 55 71
Canada – 95 91 91 90 87 71 91 79 81 – − − − − −
Central African Republic 74 69 47 47 49 – 47 47 – 47 60 30 x 16 x − 36 x 47 x
Chad 59 55 41 44 37 – 41 41 – – 78 26 20 23 36 77
Chile 96 99 95 95 93 93 95 95 – 93 – − − − − −
China 99 99 99 99 99 99 99 – – – – − − − − −
Colombia 89 92 92 92 95 88 92 92 90 94 95 64 x 54 x 54 x − 3 x
Comoros 94 96 91 94 90 – 91 91 – – 85 38 x 38 x 45 x 41 x 59 x
Congo 81 79 75 75 75 – 75 75 72 73 85 28 27 51 61 66
Cook Islands 99 99 99 99 99 99 99 99 – – – − − − − −
Costa Rica 92 95 94 94 94 93 98 94 – 96 – 77 x 40 x − − −
Côte d'Ivoire 98 95 82 82 71 – 82 82 59 81 85 44 17 45 60 76
Croatia 98 98 93 94 93 95 93 94 – – – − − − − −
Cuba 99 99 99 99 99 99 99 99 – – – 93 61 93 − −
Cyprus – 99 99 97 90 88 97 97 – 81 – − − − − −
Czechia – 98 96 94 96 84 94 94 – – – − − − − −
Democratic People's Republic of
96 99 97 99 98 99 97 97 – – 98 86 74 − − −
Korea
Democratic Republic of the Congo 83 82 81 79 80 – 81 81 – 81 85 42 39 55 56 70
Denmark – 97 97 97 95 90 – 97 – 96 – − − − − −
Djibouti 93 91 84 84 86 81 84 84 87 84 98 94 x 94 x − 20 x 32 x
Dominica 95 99 94 94 84 81 94 94 – – – − − − − −
Dominican Republic 99 99 94 89 95 31 92 90 82 70 99 73 48 65 − −
Ecuador 90 86 85 85 83 74 85 85 85 85 88 − 46 x − − −
Egypt 95 96 95 95 94 94 95 95 – – 86 68 28 68 − −
El Salvador 81 82 81 83 81 85 81 81 82 75 92 80 70 − − −
Equatorial Guinea 63 44 25 27 30 – 25 25 – – 70 54 x 40 x 62 x 23 x 38 x
Eritrea 97 97 95 95 99 88 95 95 96 95 99 45 x 43 x − 20 x 71 x
Estonia 92 93 92 92 87 88 93 92 85 – – − − − − −
Eswatini 98 96 90 90 89 75 90 90 90 88 88 60 84 63 2 x 10 x
Ethiopia 85 85 72 67 61 – 72 72 79 67 93 31 30 35 45 64
 S TAT I S T I C A L TA B L E S » 2 0 5

TABLE 4. CHILD HEALTH

Intervention coverage
Immunization for vaccine preventable diseases (%) Pneumonia Diarrhoea Malaria
2018β 2013–2018* 2013–2018* 2013–2018*
Care seeking for Treatment
Protection at children with with oral Care seeking Children
Countries birth (PAB)
against
symptoms of rehydration
Acute Respiratory salts (ORS)
for children
with fever
sleeping
under ITNs
Households
with at least
and areas BCG DTP1 DTP3 Polio3 MCV1 MCV2^ HepB3 Hib3 Rota PCV3 tetanusλ Infection (ARI)(%) (%) (%) (%) one ITN (%)

Fiji 99 99 99 99 94 94 99 99 99 99 96 − − − − −
Finland – 99 91 91 96 93 – 91 82 88 – − − − − −
France – 99 96 96 90 80 90 95 – 92 – − − − − −
Gabon 87 78 70 64 59 – 70 70 – – 85 68 x 26 x 67 x 39 x 36 x
Gambia 94 94 93 93 91 71 93 93 93 93 92 68 59 83 62 79
Georgia 97 99 93 93 98 96 93 93 79 81 – 74 x 40 x − − −
Germany – 98 93 93 97 93 87 92 68 84 – − − − − −
Ghana 98 97 97 98 92 83 97 97 94 96 89 56 49 77 52 68
Greece – 99 99 99 97 83 96 99 20 96 – − − − − −
Grenada – 98 96 96 84 74 96 96 – – – − − − − −
Guatemala 88 94 86 85 87 76 86 86 87 85 90 52 49 50 − −
Guinea 72 63 45 45 48 – 45 45 – – 80 83 55 62 27 44
Guinea-Bissau 91 89 88 89 86 – 88 88 88 88 83 34 35 51 81 90
Guyana 99 99 95 94 98 84 95 95 91 91 99 84 43 71 7 5
Haiti 83 84 64 64 69 38 64 64 58 1 81 37 39 40 18 31
Holy See – – – – – – – – – – – − − − − −
Honduras 94 94 90 90 89 94 90 90 91 90 99 64 x 60 x 62 x − −
Hungary 99 99 99 99 99 99 – 99 – 99 – − − − − −
Iceland – 97 91 91 93 95 – 91 – 90 – − − − − −
India 92 92 89 89 90 80 89 89 35 6 90 78 51 73 5 1
Indonesia 81 85 79 80 75 67 79 79 – 8 85 92 36 90 3 x 3 x
Iran (Islamic Republic of) 99 99 99 99 99 98 99 99 – – 95 76 x 61 x − − −
Iraq 95 92 84 71 83 81 84 84 60 32 75 44 25 75 − −
Ireland – 98 94 94 92 – 94 94 89 90 – − − − − −
Israel – 99 98 98 98 96 97 98 81 94 – − − − − −
Italy – 98 95 95 93 89 95 94 19 92 – − − − − −
Jamaica 93 99 97 98 89 82 97 98 – – 90 82 x 64 x − − −
Japan 99 99 99 97 97 93 – 99 – 98 – − − − − −
Jordan 94 98 96 92 92 96 96 96 93 – 90 72 44 68 − −
Kazakhstan 95 99 98 98 99 98 98 98 – 95 – 81 x 62 x − − −
Kenya 95 97 92 81 89 45 92 92 78 81 88 66 54 72 56 59
Kiribati 89 98 95 93 84 79 95 95 97 94 – 81 x 62 x 27 x − −
Kuwait 99 99 99 99 99 99 99 99 3 99 99 − − − − −
Kyrgyzstan 97 98 94 92 96 96 92 92 – 92 – 60 33 56 − −
Lao People's Democratic Republic 79 73 68 67 69 57 68 68 – 56 90 40 56 58 50 61
Latvia 95 97 96 96 98 94 96 96 79 82 – − − − − −
Lebanon – 96 83 81 82 63 80 85 – 82 – 74 x 44 x − − −
Lesotho 98 98 93 90 90 82 93 93 70 93 85 63 53 61 − −
Liberia 92 99 84 84 91 – 84 84 74 84 89 51 60 78 44 62
Libya 99 98 97 97 97 96 97 97 97 96 – − − − − −
Liechtenstein – – – – – – – – – – – − − − − −
Lithuania 96 95 92 92 92 92 93 92 1 82 – − − − − −
Luxembourg – 99 99 99 99 90 96 99 89 96 – − − − − −
Madagascar 70 81 75 76 62 – 75 75 78 75 78 41 15 46 73 80
Malawi 92 96 92 91 87 72 92 92 90 92 89 78 65 54 68 82
Malaysia 98 99 99 99 96 99 99 99 – – 92 − − − − −
Maldives 99 99 99 99 99 99 99 99 – – 99 22 x 75 86 − −
Mali 83 82 71 73 70 – 71 71 55 68 85 71 21 53 73 85
Malta – 99 97 97 96 95 98 97 – – – − − − − −
Marshall Islands 98 97 81 80 83 61 84 72 42 67 – − 38 x 63 x − −
Mauritania 90 89 81 81 78 – 81 81 76 77 80 34 25 35 18 49
Mauritius 99 98 97 98 99 99 97 97 95 96 95 − − − − −
Mexico 96 90 88 88 97 99 55 88 77 88 96 73 61 − − −
Micronesia (Federated States of) 80 97 75 75 73 48 83 59 52 67 – − − − − −
Monaco 89 99 99 99 87 79 99 99 – – – − − − − −
Mongolia 99 99 99 99 99 98 99 99 – 26 – 70 42 − − −
Montenegro 83 95 87 87 58 83 73 87 – – – 89 x 16 x 74 − −
Montserrat – – – – – – – – – – – − − − − −
Morocco 99 99 99 99 99 99 99 99 99 99 88 70 x 22 x − − −
Mozambique 95 90 80 80 85 59 80 80 80 80 86 57 46 69 73 82
Myanmar 90 95 91 91 93 87 91 91 – 91 90 58 62 65 19 27
Namibia 94 94 89 84 82 50 89 89 92 61 88 68 72 63 6 24
 206 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 4. CHILD HEALTH

Intervention coverage
Immunization for vaccine preventable diseases (%) Pneumonia Diarrhoea Malaria
2018β 2013–2018* 2013–2018* 2013–2018*
Care seeking for Treatment
Protection at children with with oral Care seeking Children
Countries birth (PAB)
against
symptoms of rehydration
Acute Respiratory salts (ORS)
for children
with fever
sleeping
under ITNs
Households
with at least
and areas BCG DTP1 DTP3 Polio3 MCV1 MCV2^ HepB3 Hib3 Rota PCV3 tetanusλ Infection (ARI)(%) (%) (%) (%) one ITN (%)

Nauru 99 99 90 90 99 94 90 90 – – – 69 x 23 x 51 x − −
Nepal 96 96 91 91 91 69 91 91 – 82 89 85 37 80 − −
Netherlands – 97 93 93 93 89 92 93 – 93 – − − − − −
New Zealand – 95 93 93 92 90 93 92 86 96 – − − − − −
Nicaragua 98 99 98 99 99 95 98 98 98 98 90 58 x 65 x − − −
Niger 87 91 79 79 77 48 79 79 79 79 81 59 41 75 96 87
Nigeria 53 70 57 57 65 – 57 57 – 57 60 73 40 72 49 65
Niue 99 99 99 99 99 99 99 99 99 99 – − − − − −
North Macedonia 97 97 91 91 83 97 91 91 – – – 93 x 62 x − − −
Norway – 99 96 96 96 93 – 96 93 94 – − − − − −
Oman 99 99 99 99 99 99 99 99 – 99 99 56 59 − − −
Pakistan 86 83 75 75 76 67 75 75 58 79 85 84 37 81 0 4
Palau – 99 95 98 90 75 98 92 93 89 – − − − − −
Panama 99 96 88 88 98 99 88 88 95 92 – 82 52 − − −
Papua New Guinea 69 67 61 67 61 – 61 61 – 43 70 63 30 48 − 69
Paraguay 91 91 88 88 93 83 88 88 91 94 95 89 28 86 − −
Peru 81 90 84 83 85 66 84 84 85 82 95 62 32 61 − −
Philippines 75 66 65 66 67 40 65 65 – 43 90 67 45 55 − −
Poland 92 98 95 87 93 92 91 95 – 60 – − − − − −
Portugal – 99 99 99 99 96 98 99 – 98 – − − − − −
Qatar 99 99 98 98 99 95 98 98 95 98 – − − − − −
Republic of Korea 98 98 98 98 98 97 98 98 – 97 – − − − − −
Republic of Moldova 96 96 93 94 93 96 94 92 75 94 – 79 x 42 x − − −
Romania 96 94 86 86 90 81 93 86 – – – − − − − −
Russian Federation 95 97 97 96 98 97 97 – – 82 – − − − − −
Rwanda 97 98 97 97 99 96 97 97 98 97 95 54 28 56 68 84
Saint Kitts and Nevis 97 99 97 97 96 96 98 98 – – – − − − − −
Saint Lucia 99 99 95 95 86 68 95 95 – – – − − − − −
Saint Vincent and the Grenadines 99 99 97 99 99 99 97 97 – – – − − − − −
Samoa 62 56 34 31 31 13 34 34 – – – 78 63 59 − −
San Marino – 94 90 93 89 84 78 91 – 58 – − − − − −
Sao Tome and Principe 96 97 95 95 95 76 95 95 95 95 99 69 49 66 61 78
Saudi Arabia 98 96 96 98 98 97 97 96 97 98 – − − − − −
Senegal 83 83 81 81 82 63 82 82 80 81 95 60 28 51 61 84
Serbia 98 98 96 96 92 90 91 96 – 48 – 90 x 36 x − − −
Seychelles 97 99 99 99 96 97 99 99 99 16 100 − − − − −
Sierra Leone 90 98 90 90 80 55 90 90 92 90 90 74 78 70 60 71
Singapore 98 98 96 96 95 84 96 96 – 82 – − − − − −
Slovakia – 99 96 96 96 97 96 96 – 96 – − − − − −
Slovenia – 97 93 93 93 94 – 93 – 60 – − − − − −
Solomon Islands 83 86 85 85 93 54 85 85 – 84 85 79 37 62 70 86
Somalia 37 52 42 47 46 – 42 42 – – 67 13 x 13 x − 11 x 12 x
South Africa 70 81 74 74 70 50 74 74 70 73 90 88 51 68 − −
South Sudan 52 58 49 50 51 – 49 49 – – 68 48 x 39 x 57 46 66
Spain – 97 93 93 97 94 94 94 – 93 – − − − − −
Sri Lanka 99 99 99 99 99 99 99 99 – – 99 52 54 92 3 x 6
State of Palestine 99 99 99 99 99 99 99 99 99 96 – 77 32 − − −
Sudan 88 97 93 93 88 72 93 93 94 93 80 48 20 − 30 x 25 x
Suriname – 95 95 95 98 39 95 95 – – 93 76 x 42 x − 43 x 61 x
Sweden 26 99 97 97 97 95 92 97 – 97 – − − − − −
Switzerland – 97 96 96 96 89 72 95 – 85 – − − − − −
Syrian Arab Republic 79 67 47 53 63 54 47 48 – – 91 77 x 50 x − − −
Tajikistan 99 98 96 96 98 97 96 96 96 – – 69 62 44 1 x 2 x
Thailand 99 99 97 97 96 87 97 – – – 98 80 73 76 − −
Timor-Leste 95 92 83 83 77 54 83 83 – – 83 71 70 58 55 64
Togo 83 92 88 66 85 – 88 88 89 88 83 49 19 56 70 85
Tokelau – – – – – – – – – – – − − − − −
Tonga 88 86 81 83 85 85 81 81 – – – − − 64 x − −
Trinidad and Tobago – 99 99 99 90 92 99 99 – 99 – 74 x 45 x − − −
Tunisia 92 98 97 97 96 99 97 97 – – 96 60 x 65 x − − −
Turkey 96 99 98 98 96 87 98 98 – 97 95 − − − − −
Turkmenistan 98 99 99 99 99 99 99 99 – – – 59 47 59 − −
Turks and Caicos Islands – – – – – – – – – – – − − − − −
 S TAT I S T I C A L TA B L E S » 2 0 7

TABLE 4. CHILD HEALTH

Intervention coverage
Immunization for vaccine preventable diseases (%) Pneumonia Diarrhoea Malaria
2018β 2013–2018* 2013–2018* 2013–2018*
Care seeking for Treatment
Protection at children with with oral Care seeking Children
Countries birth (PAB)
against
symptoms of rehydration
Acute Respiratory salts (ORS)
for children
with fever
sleeping
under ITNs
Households
with at least
and areas BCG DTP1 DTP3 Polio3 MCV1 MCV2^ HepB3 Hib3 Rota PCV3 tetanusλ Infection (ARI)(%) (%) (%) (%) one ITN (%)

Tuvalu 99 99 89 89 88 81 89 89 – – – − 44 x 79 x − −
Uganda 88 99 93 88 86 – 93 93 36 92 85 80 47 81 62 78
Ukraine 90 65 50 48 91 90 52 39 – – – 92 x 59 x − − −
United Arab Emirates 95 99 99 99 99 99 99 99 99 99 – − − − − −
United Kingdom – 98 94 94 92 88 – 94 91 92 – − − − − −
United Republic of Tanzania 99 99 98 91 99 84 98 98 98 98 90 55 45 75 55 78
United States – 97 94 93 92 94 91 92 73 92 – − − − − −
Uruguay 98 96 91 91 97 91 91 91 – 93 – 91 − − − −
Uzbekistan 96 99 98 98 96 99 98 98 84 96 – 68 x 28 x − − −
Vanuatu 94 93 85 85 75 – 85 85 – – 78 72 48 57 51 83
Venezuela (Bolivarian Republic of) 92 84 60 53 74 39 60 60 – – 70 72 x 38 x − − −
Viet Nam 95 78 75 90 97 90 75 75 – – 94 81 51 − 9 x 10 x
Yemen 64 75 65 59 64 46 65 65 64 64 70 34 25 33 − −
Zambia 91 94 90 90 94 65 90 90 91 90 85 70 64 75 41 68
Zimbabwe 95 94 89 89 88 78 89 89 90 89 87 51 41 50 9 48

SUMMARY
East Asia and Pacific 93 93 91 92 92 87 88 35 1 14 89** − − − − −
Europe and Central Asia 93 97 94 93 95 91 84 76 24 77 – − − − − −
Eastern Europe and Central
96 96 93 93 96 94 94 61 16 72 – − − − − −
Asia
Western Europe 69 98 95 94 94 88 71 94 35 84 – − − − − −
Latin America and Caribbean 91 90 85 85 89 78 78 85 73 79 92 − − − − −
Middle East and North Africa 93 94 90 88 89 87 90 90 32 39 87 59 28 − − −
North America – 97 94 93 92 93 89 92 74 91 – − − − − −
South Asia 91 91 87 87 87 78 87 87 36 29 89 75 50 73 4 2
Sub-Saharan Africa 79 84 76 74 74 26 76 76 50 72 81 57 38 60 53 68
Eastern and Southern Africa 86 88 81 78 77 40 81 81 74 77 86 56 40 60 51 67
West and Central Africa 73 79 70 70 71 12 70 70 28 67 76 58 36 61 55 70
Least developed countries 86 87 80 79 78 40 80 80 50 76 86 51 42 57 51 64
World 89 90 86 85 86 69 84 72 35 47 86** 68 44 67 − −
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES NOTES

BCG – Percentage of live births who
received bacilli Calmette-Guérin (vaccine
against tuberculosis).
DTP1 – Percentage of surviving infants who
received the first dose of diphtheria,
pertussis and tetanus vaccine.
DTP3 – Percentage of surviving infants who
received three doses of diphtheria, pertussis
and tetanus vaccine.
Polio3 – Percentage of surviving infants
who received three doses of the polio
vaccine.
MCV1 – Percentage of surviving infants who
received the first dose of the measles-
containing vaccine.
MCV2 – Percentage of children who
received the second dose of measles-
containing vaccine as per national schedule.
HepB3 – Percentage of surviving infants
who received three doses of hepatitis B
vaccine.
Hib3 – Percentage of surviving infants who
received three doses of Haemophilus
influenzae type b vaccine.
Rota – Percentage of surviving infants who
received the last dose of rotavirus vaccine as
recommended.
PCV3 – Percentage of surviving infants who
received three doses of pneumococcal
conjugate vaccine.
Protection at birth (PAB) – Percentage of
newborns protected at birth against tetanus
with tetanus toxoid.
Care seeking for children with
symptoms of Acute Respiratory
Infection (ARI) – Percentage of children
under age 5 with symptoms of pneumonia
(cough and fast or difficult breathing due to a
problem in the chest) for whom advice or
treatment was sought from a health facility
or provider.
Diarrhoea treatment with oral
rehydration salts (ORS) – Percentage of
children under age 5 who had diarrhoea in
the two weeks preceding the survey and
who received oral rehydration salts (ORS
packets or pre-packaged ORS fluids).
Care seeking for children with fever
– Percentage of children under five years of
age with fever for whom advice or treatment
was sought from a health facility or provider.
Excludes drug vendor, stores, shops and
traditional healer. In some countries,
particularly non-malaria endemic countries,
pharmacies have also been excluded from
the calculation.
Children sleeping under ITNs –
Percentage of children under age 5 who
slept under an insecticide-treated mosquito
net the night prior to the survey.
Households with at least one ITN –
Percentage of households with at least one
insecticide-treated mosquito net.
Immunization – WHO and UNICEF
estimates of national immunization
coverage, 2018 revision. Last update:
July 2019.
Care seeking for children with
symptoms of Acute Respiratory
Infection (ARI) – DHS, MICS and other
national household surveys. Last update:
May 2019.
Diarrhoea treatment with oral
rehydration salts (ORS) – DHS, MICS
and other national household surveys.
Last update: May 2019.
Care seeking for children with fever
– DHS, MICS, MIS and other national
household surveys. Last update: May
2019.
Children sleeping under ITNs – DHS,
MICS, MIS and other national household
surveys. Last update: May 2019.
Households with at least one ITN
– DHS, MICS, MIS and other national
household surveys. Last update: May
2019.
− Data not available or vaccine not in the national schedule.
x Data refer to years or periods other than those specified in the column
heading. Such data are not included in the calculation of regional and
global averages. Estimates from data years prior to 2000 are not displayed.
β For the calculation of regional and global vaccination coverage, the nation-
al coverage is considered to be 0% for the countries that did not introduce
the vaccine in their national schedule or did not report coverage, with the
exception of BCG that is only recommended in countries or settings with
a high incidence of tuberculosis or high leprosy burden. World Population
Prospects (2019 revision) estimates of target populations were used in the
calculation of global and regional aggregates.
^ Generally, the second dose of measles-containing vaccine (MCV2) is
recommended for administration during the second year of life; however,
in many countries, MCV2 is scheduled after the second year. World Popu-
lation Prospects (2019 revision) estimates of the second year of life target
population were used to calculate regional and global aggregates.
λ WHO and UNICEF employ a complex process employing administrative
data, surveys (routine and supplemental), serosurveys, and information on
other vaccines to calculate the percentage of births that can be considered
as protected against tetanus because pregnant women were given two
doses or more of tetanus toxoid (TT) vaccine. The complete methodology
can be found at <http://who.int/immunization/monitoring_surveillance/
data/en/>.
* Data refer to the most recent year available during the period specified in
the column heading.
** Excludes China.
 208 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 5. HIV/AIDS: EPIDEMIOLOGY

HIV incidence per 1,000 uninfected population AIDS-related mortality per 100,000 population Number of children living with HIV
2018 2018 2018
Countries Children Adolescents Adolescent Adolescent Children Adolescents Adolescent Adolescent Children Adolescents Adolescent Adolescent
and areas 0–14 10–19 girls 10–19 boys 10–19 0–14 10–19 girls 10–19 boys 10–19 0–14 10–19 girls 10–19 boys 10–19

Afghanistan 0.01 <0.01 <0.01 <0.01 0.28 0.07 0.07 0.06 <500 <200 <100 <100
Albania – – – – – – – – – – – –
Algeria 0.01 0.02 0.02 0.01 0.14 0.02 <0.01 <0.01 <500 <200 <200 <100
Andorra – – – – – – – – – – – –
Angola 1.35 1.10 1.91 0.30 36.66 9.91 10.88 8.93 38,000 21,000 14,000 7,200
Anguilla – – – – – – – – – – – –
Antigua and Barbuda 0.12 0.11 0.23 0.23 3.94 <0.01 <0.01 <0.01 <100 <100 <100 <100
Argentina 0.03 0.06 0.05 0.08 0.07 0.08 0.09 0.08 1,800 2,300 1,100 1,200
Armenia – – – – – – – – – – – –
Australia <0.01 <0.01 <0.01 0.01 <0.01 <0.01 <0.01 <0.01 <100 <100 <100 <100
Austria – – – – – – – – – – – –
Azerbaijan – – – – – – – – – – – –
Bahamas 0.79 0.26 0.23 0.22 21.03 9.72 7.94 7.61 <200 <200 <100 <100
Bahrain – – – – – – – – – – – –
Bangladesh <0.01 <0.01 <0.01 <0.01 0.07 0.01 0.01 0.01 <500 <200 <200 <100
Barbados – – – – – – – – – – – –
Belarus 0.05 0.08 0.12 0.04 0.69 <0.01 <0.01 <0.01 <500 <200 <100 <100
Belgium – – – – – – – – – – – –
Belize 0.64 1.55 1.74 1.36 14.87 3.82 2.57 2.52 <200 <500 <200 <200
Benin 0.26 0.34 0.50 0.18 7.39 4.80 4.63 4.90 4,600 3,800 2,100 1,600
Bhutan – – – – – – – – – – – –
Bolivia (Plurinational State of) 0.04 0.06 0.06 0.06 1.10 0.85 0.82 0.88 620 680 <500 <500
Bosnia and Herzegovina – – – – – – – – – – – –
Botswana 1.27 5.58 9.30 1.99 71.79 85.42 84.91 85.92 14,000 17,000 9,600 7,500
Brazil – – – – – – – – – – – –
British Virgin Islands – – – – – – – – – – – –
Brunei Darussalam – – – – – – – – – – – –
Bulgaria – – – – – – – – – – – –
Burkina Faso 0.21 0.15 0.22 0.09 5.55 6.41 5.40 7.38 9,100 8,700 4,600 4,100
Burundi 0.41 0.11 0.18 0.03 12.62 12.65 11.79 13.61 11,000 9,300 4,900 4,400
Cabo Verde – – – – – – – – – – – –
Cambodia 0.06 0.03 0.04 0.02 0.71 0.74 0.65 0.82 3,300 3,100 1,600 1,600
Cameroon 1.18 1.30 2.25 0.37 35.35 22.46 22.42 22.51 43,000 35,000 21,000 14,000
Canada – – – – – – – – – – – –
Central African Republic 1.46 0.94 1.31 0.57 43.69 31.89 27.71 35.97 11,000 8,300 4,500 3,800
Chad 0.78 0.79 1.05 0.54 20.59 11.70 11.47 11.93 16,000 12,000 6,600 5,400
Chile 0.02 0.12 0.08 0.15 0.46 0.08 0.08 0.08 <500 <500 <200 <500
China – – – – – – – – – – – –
Colombia 0.14 0.05 0.03 0.08 – – – – 3,600 3,100 1,400 1,600
Comoros – – – – – – – – – – – –
Congo 1.43 1.26 2.30 0.23 40.11 15.89 16.29 15.50 7,700 5,400 3,500 1,900
Cook Islands – – – – – – – – – – – –
Costa Rica – – – – – – – – – – – –
Côte d'Ivoire 0.68 0.61 1.07 0.16 22.72 17.82 16.12 19.51 31,000 26,000 14,000 11,000
Croatia – – – – – – – – – – – –
Cuba 0.01 0.08 0.06 0.09 0.33 0.08 0.17 0.16 <100 <200 <100 <100
Cyprus – – – – – – – – – – – –
Czechia – – – – – – – – – – – –
Democratic People's Republic of
– – – – – – – – – – – –
Korea
Democratic Republic of the Congo 0.42 0.25 0.43 0.07 9.85 7.00 7.07 6.92 64,000 44,000 25,000 20,000
Denmark – – – – – – – – – – – –
Djibouti 0.86 0.38 0.53 0.23 20.97 16.23 15.88 16.57 810 690 <500 <500
Dominica – – – – – – – – <100 <100 <100 <100
Dominican Republic 0.09 0.35 0.38 0.31 2.14 1.30 1.36 1.23 1,400 2,300 1,300 1,100
Ecuador 0.03 0.07 0.07 0.07 0.42 0.13 0.13 0.13 660 620 <500 <500
Egypt 0.01 0.02 0.02 0.02 0.22 0.02 0.02 0.01 <500 <500 <200 <200
El Salvador 0.10 0.21 0.17 0.25 2.68 0.79 0.81 0.94 610 830 <500 <500
Equatorial Guinea 4.89 2.86 4.13 1.60 110.08 36.17 31.55 40.69 5,300 2,500 1,400 1,100
Eritrea 0.22 0.16 0.28 0.04 6.17 3.94 3.91 3.97 1,300 1,000 570 <500
Estonia – – – – – – – – – – – –
Eswatini 5.66 11.16 22.56 0.52 76.48 74.46 85.87 63.11 11,000 12,000 7,700 3,800
Ethiopia 0.18 0.27 0.47 0.08 4.63 3.43 3.40 3.47 36,000 36,000 21,000 15,000
Fiji – – – – – – – – – – – –
Finland – – – – – – – – – – – –
 S TAT I S T I C A L TA B L E S » 2 0 9

TABLE 5. HIV/AIDS: EPIDEMIOLOGY

HIV incidence per 1,000 uninfected population AIDS-related mortality per 100,000 population Number of children living with HIV
2018 2018 2018
Countries Children Adolescents Adolescent Adolescent Children Adolescents Adolescent Adolescent Children Adolescents Adolescent Adolescent
and areas 0–14 10–19 girls 10–19 boys 10–19 0–14 10–19 girls 10–19 boys 10–19 0–14 10–19 girls 10–19 boys 10–19

France <0.01 0.05 0.05 0.06 0.13 0.01 0.02 0.02 <500 600 <500 <500
Gabon 1.43 1.22 2.28 0.19 37.50 18.93 19.59 18.78 3,200 2,200 1,400 840
Gambia 0.77 0.33 0.56 0.09 17.64 7.04 6.68 7.78 1,900 920 520 <500
Georgia – – – – – – – – – – – –
Germany <0.01 0.02 0.01 0.02 0.04 0.01 <0.01 <0.01 <200 <200 <100 <200
Ghana 0.81 0.69 1.26 0.16 24.53 14.97 13.61 16.27 30,000 21,000 13,000 8,400
Greece – – – – – – – – – – – –
Grenada 0.09 0.11 <0.01 0.21 3.19 <0.01 <0.01 <0.01 <100 <100 <100 <100
Guatemala 0.11 0.07 0.08 0.05 2.86 1.36 1.41 1.31 2,000 1,900 990 930
Guinea 0.62 0.63 1.06 0.21 17.30 8.32 8.56 8.08 10,000 7,800 4,800 3,100
Guinea-Bissau 2.46 0.93 1.31 0.56 57.90 33.74 31.39 36.08 5,700 3,000 1,600 1,400
Guyana 0.37 0.31 0.42 0.20 8.18 2.08 1.40 1.37 <500 <500 <200 <100
Haiti 0.69 0.80 1.38 0.22 14.38 6.28 6.14 6.33 8,700 8,300 5,100 3,200
Holy See – – – – – – – – – – – –
Honduras 0.07 0.15 0.12 0.18 1.98 0.75 0.71 0.79 890 1,300 610 710
Hungary – – – – – – – – – – – –
Iceland – – – – – – – – – – – –
India – – – – – – – – – – – –
Indonesia 0.14 0.27 0.20 0.33 3.45 0.63 0.59 0.67 18,000 18,000 6,900 11,000
Iran (Islamic Republic of) 0.01 0.02 0.02 0.02 0.23 0.16 0.15 0.17 880 660 <500 <500
Iraq – – – – – – – – – – – –
Ireland <0.01 0.02 0.02 0.02 <0.01 <0.01 <0.01 <0.01 <100 <100 <100 <100
Israel <0.01 0.03 0.02 0.03 0.08 <0.01 <0.01 <0.01 <100 <100 <100 <100
Italy 0.02 0.03 0.03 0.03 0.35 0.02 0.04 0.03 <500 <500 <200 <200
Jamaica 0.11 0.42 0.41 0.42 1.14 0.41 0.42 0.40 <500 <500 <500 <500
Japan – – – – – – – – – – – –
Jordan – – – – – – – – – – – –
Kazakhstan 0.03 0.04 0.05 0.03 0.45 0.04 <0.01 <0.01 <500 <200 <200 <100
Kenya 1.12 1.45 2.33 0.56 27.56 26.64 25.31 27.94 120,000 130,000 71,000 57,000
Kiribati – – – – – – – – – – – –
Kuwait – – – – – – – – – – – –
Kyrgyzstan 0.03 0.02 0.03 0.02 0.48 0.09 <0.01 <0.01 <500 <200 <100 <100
Lao People's Democratic Republic 0.09 0.08 0.09 0.07 2.11 0.61 0.69 0.53 700 <500 <500 <200
Latvia – – – – – – – – – – – –
Lebanon – – – – – – – – – – – –
Lesotho 6.31 8.10 14.00 2.52 95.13 51.44 53.65 48.77 12,000 13,000 8,300 4,800
Liberia 0.40 0.58 0.90 0.26 14.66 12.33 10.60 13.99 3,700 3,300 1,900 1,400
Libya 0.04 0.03 0.03 0.03 1.06 0.27 0.18 0.17 <500 <200 <100 <100
Liechtenstein – – – – – – – – – – – –
Lithuania – – – – – – – – – – – –
Luxembourg – – – – – – – – – – – –
Madagascar 0.11 0.47 0.37 0.57 2.51 0.94 0.82 1.01 1,900 3,800 1,600 2,200
Malawi 1.20 2.64 4.75 0.56 31.39 24.90 25.00 24.79 74,000 75,000 44,000 31,000
Malaysia <0.01 0.28 0.01 0.56 0.06 0.25 0.07 0.43 <500 2,500 <500 2,200
Maldives – – – – – – – – – – – –
Mali 1.03 1.15 1.85 0.47 24.84 9.30 9.43 9.17 19,000 14,000 8,800 5,300
Malta – – – – – – – – – – – –
Marshall Islands – – – – – – – – – – – –
Mauritania 0.06 0.01 0.01 0.01 1.37 0.78 0.68 0.88 <500 <200 <100 <100
Mauritius 0.15 0.19 0.23 0.14 2.97 1.60 1.09 1.05 <100 <100 <100 <100
Mexico 0.02 0.03 0.02 0.05 – – – – 2,300 2,400 1,000 1,400
Micronesia (Federated States of) – – – – – – – – – – – –
Monaco – – – – – – – – – – – –
Mongolia – – – – – – – – – – – –
Montenegro – – – – – – – – – – – –
Montserrat – – – – – – – – – – – –
Morocco 0.02 0.05 0.05 0.05 0.14 0.07 0.07 0.06 560 700 <500 <500
Mozambique 3.05 7.16 11.63 2.84 62.88 37.24 39.24 35.29 140,000 130,000 86,000 43,000
Myanmar 0.18 0.43 0.41 0.45 2.75 1.59 1.58 1.61 9,800 11,000 5,500 5,300
Namibia 1.24 3.32 4.97 1.68 35.75 32.44 35.15 30.11 11,000 11,000 5,900 4,700
Nauru – – – – – – – – – – – –
Nepal 0.03 0.02 0.02 0.01 0.48 0.20 0.22 0.21 1,400 1,000 520 500
Netherlands – – – – – – – – – – – –
New Zealand – – – – – – – – – – – –
Nicaragua 0.02 0.03 0.03 0.03 0.53 0.24 0.17 0.16 <500 <200 <100 <100
 2 10 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 5. HIV/AIDS: EPIDEMIOLOGY

HIV incidence per 1,000 uninfected population AIDS-related mortality per 100,000 population Number of children living with HIV
2018 2018 2018
Countries Children Adolescents Adolescent Adolescent Children Adolescents Adolescent Adolescent Children Adolescents Adolescent Adolescent
and areas 0–14 10–19 girls 10–19 boys 10–19 0–14 10–19 girls 10–19 boys 10–19 0–14 10–19 girls 10–19 boys 10–19

Niger 0.09 0.05 0.06 0.03 2.01 1.46 1.36 1.56 2,500 2,200 1,100 1,000
Nigeria 0.79 0.90 1.30 0.53 17.04 7.05 6.87 7.25 140,000 120,000 70,000 51,000
Niue – – – – – – – – – – – –
North Macedonia – – – – – – – – – – – –
Norway – – – – – – – – – – – –
Oman – – – – – – – – – – – –
Pakistan 0.05 0.06 0.06 0.05 1.15 0.10 0.11 0.09 5,500 3,000 1,700 1,300
Palau – – – – – – – – – – – –
Panama 0.05 0.16 0.16 0.17 0.80 0.14 0.29 0.28 <500 <500 <200 <200
Papua New Guinea 0.24 0.19 0.28 0.12 – – – – 2,900 2,400 1,300 1,100
Paraguay 0.05 0.31 0.24 0.36 1.46 0.74 0.76 0.73 <500 860 <500 <500
Peru 0.04 0.05 0.04 0.06 0.77 0.24 0.25 0.24 1,600 1,300 600 650
Philippines 0.01 0.30 0.04 0.55 0.14 0.31 0.07 0.54 <500 6,700 <500 6,200
Poland – – – – – – – – – – – –
Portugal <0.01 0.04 0.03 0.05 0.07 <0.01 <0.01 <0.01 <100 <100 <100 <100
Qatar – – – – – – – – – – – –
Republic of Korea – – – – – – – – – – – –
Republic of Moldova 0.17 0.09 0.12 0.06 3.91 0.71 0.98 0.91 <500 <200 <100 <100
Romania <0.01 0.02 0.03 0.02 0.07 0.09 0.10 0.09 <100 <500 <500 <500
Russian Federation – – – – – – – – – – – –
Rwanda 0.20 0.34 0.59 0.08 5.91 8.46 8.01 8.91 12,000 13,000 7,200 6,000
Saint Kitts and Nevis – – – – – – – – <100 <100 <100 <100
Saint Lucia – – – – – – – – <100 <100 <100 <100
Saint Vincent and the Grenadines – – – – – – – – <100 <100 <100 <100
Samoa – – – – – – – – – – – –
San Marino – – – – – – – – – – – –
Sao Tome and Principe 0.06 0.12 0.08 0.16 3.11 3.66 3.68 3.64 <100 <100 <100 <100
Saudi Arabia – – – – – – – – – – – –
Senegal 0.16 0.09 0.15 0.03 5.38 2.78 2.64 2.92 4,500 3,200 1,700 1,400
Serbia – – – – – – – – – – – –
Seychelles – – – – – – – – – – – –
Sierra Leone 0.59 1.22 1.79 0.65 17.90 10.29 9.96 10.62 6,600 6,500 4,000 2,500
Singapore – – – – – – – – – – – –
Slovakia – – – – – – – – – – – –
Slovenia – – – – – – – – – – – –
Solomon Islands – – – – – – – – – – – –
Somalia 0.05 0.01 0.03 <0.01 1.79 1.36 1.33 1.38 1,300 940 <500 <500
South Africa 2.48 8.61 15.70 1.87 26.80 24.01 28.58 19.50 260,000 310,000 200,000 110,000
South Sudan 1.34 1.23 1.73 0.74 35.91 13.63 13.68 13.59 16,000 11,000 6,100 4,500
Spain <0.01 0.03 0.02 0.05 – – – – <100 <500 <100 <200
Sri Lanka – – – – – – – – – – – –
State of Palestine – – – – – – – – – – – –
Sudan 0.13 0.07 0.09 0.05 3.04 0.67 0.69 0.66 4,200 2,000 1,100 850
Suriname 0.08 0.27 0.35 0.23 1.32 <0.01 <0.01 <0.01 <100 <100 <100 <100
Sweden – – – – – – – – – – – –
Switzerland – – – – – – – – – – – –
Syrian Arab Republic – – – – – – – – – – – –
Tajikistan 0.04 0.02 0.02 0.02 0.55 0.06 0.11 0.11 540 <200 <100 <100
Thailand 0.01 0.22 0.18 0.27 0.73 1.45 1.31 1.60 3,200 9,100 4,400 4,700
Timor-Leste – – – – – – – – – – – –
Togo 1.07 0.51 0.85 0.17 30.51 18.69 17.00 20.48 12,000 8,700 4,800 4,000
Tokelau – – – – – – – – – – – –
Tonga – – – – – – – – – – – –
Trinidad and Tobago – – – – – – – – – – – –
Tunisia – – – – – – – – – – – –
Turkey – – – – – – – – – – – –
Turkmenistan – – – – – – – – – – – –
Turks and Caicos Islands – – – – – – – – – – – –
Tuvalu – – – – – – – – – – – –
Uganda 1.03 1.73 3.08 0.41 29.02 20.76 20.15 21.36 100,000 90,000 54,000 35,000
Ukraine 0.02 0.09 0.07 0.10 0.76 0.22 0.20 0.24 850 1,000 510 520
United Arab Emirates – – – – – – – – – – – –
United Kingdom – – – – – – – – – – – –
United Republic of Tanzania 0.95 1.91 2.79 1.01 22.45 15.77 15.44 16.08 92,000 93,000 54,000 39,000
United States – – – – – – – – – – – –
 S T A T I S T I C A L T A B L E S » 2 11

TABLE 5. HIV/AIDS: EPIDEMIOLOGY

HIV incidence per 1,000 uninfected population AIDS-related mortality per 100,000 population Number of children living with HIV
2018 2018 2018
Countries Children Adolescents Adolescent Adolescent Children Adolescents Adolescent Adolescent Children Adolescents Adolescent Adolescent
and areas 0–14 10–19 girls 10–19 boys 10–19 0–14 10–19 girls 10–19 boys 10–19 0–14 10–19 girls 10–19 boys 10–19

Uruguay 0.03 0.13 0.10 0.15 0.73 0.20 <0.01 <0.01 <200 <200 <100 <100
Uzbekistan 0.30 0.03 0.04 0.03 3.93 0.43 0.43 0.44 6,000 1,500 750 720
Vanuatu – – – – – – – – – – – –
Venezuela (Bolivarian Republic of) – – – – – – – – – – – –
Viet Nam 0.04 0.03 0.04 0.02 0.50 0.13 0.16 0.10 5,000 3,000 1,600 1,400
Yemen 0.02 0.07 0.03 0.10 0.38 0.11 0.06 0.12 <500 680 <200 <500
Zambia 1.68 4.31 6.79 1.82 36.43 24.50 24.69 24.16 62,000 64,000 39,000 25,000
Zimbabwe 2.02 3.67 5.94 1.42 53.17 49.51 49.01 50.21 84,000 81,000 46,000 36,000

SUMMARY
East Asia and Pacific 0.04 0.10 0.07 0.13 0.84 0.27 0.25 0.29 50,000 62,000 25,000 36,000
Europe and Central Asia – – – – – – – – – – – –
Eastern Europe and Central Asia – – – – – – – – – – – –
Western Europe – – – – – – – – – – – –
Latin America and Caribbean 0.08 0.12 0.13 0.12 1.68 0.63 0.63 0.62 42,000 48,000 25,000 23,000
Middle East and North Africa 0.01 0.03 0.02 0.03 0.23 0.06 0.05 0.06 3,500 3,300 1,500 1,800
North America – – – – – – – – – – – –
South Asia 0.03 0.05 0.05 0.04 0.54 0.15 0.15 0.15 64,000 61,000 30,000 31,000
Sub-Saharan Africa 0.85 1.42 2.33 0.52 19.69 12.48 12.53 12.45 1,550,000 1,460,000 880,000 580,000
Eastern and Southern Africa 1.03 2.14 3.57 0.72 22.65 15.72 16.08 15.35 1,110,000 1,120,000 680,000 440,000
West and Central Africa 0.67 0.67 1.04 0.32 16.76 9.19 8.86 9.52 440,000 340,000 200,000 140,000
Least developed countries 0.20 0.36 0.58 0.15 13.04 7.37 7.38 7.36 810,000 720,000 430,000 290,000
World 0.25 0.33 0.51 0.16 5.18 2.69 2.76 2.64 1,730,000 1,650,000 970,000 680,000
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES

HIV incidence per 1,000 uninfected population – HIV incidence per 1,000 uninfected
Estimated number of new HIV infections per 1,000 uninfected population – UNAIDS 2019 estimates.
population at risk of HIV infection. Last update: July 2019.
AIDS-related mortality per 100,000 population – Estimated AIDS-related mortality per 100,000
number of AIDS-related deaths per 100,000 population. population – UNAIDS 2019 estimates.
Number of children living with HIV – Estimated number of Last update: July 2019.
children living with HIV. Number of children living with HIV
– UNAIDS 2019 estimates. Last update:
July 2019.

NOTES
– Data not available.
Due to rounding of the estimates,
disaggregates may not add up to the
total.
 2 12 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 6. HIV/AIDS: INTERVENTION COVERAGE

Comprehensive knowledge of HIV Condom use among adolescents Adolescents age 15–19 tested for
Pregnant Children living with HIV among adolescents age 15–19 age 15–19 with multiple partners HIV in the last 12 months and
women living receiving ART (%) (%) (%) received results (%)
with HIV Early infant 2018 2012–2018* 2012–2018* 2012–2018*
Countries receiving ARVs HIV diagnosis
for PMTCT (%) (%) children adolescents
and areas 2018 2018 0–14 10–19 male female male female male female

Afghanistan 11.1 1.2 17.2 34.5 4.3 y 0.6 y – – 0.0 y 1.2 y

Albania – – – – 19.6 35.3 – – 0.1 1.0
Algeria 74.1 46.7 >95 >95 – 6.8 – – – 0.7
Andorra – – – – – – – – – –
Angola 38.2 1.4 12.9 – 29.4 31.1 39.1 30.5 4.2 15.7
Anguilla – – – – – – – – – –
Antigua and Barbuda – – <1 – 55.1 x 40.2 x 100 x 53.8 x – –
Argentina >95 70.6 92.1 – – 35.7 – – – –
Armenia – – – – 8.9 14.7 – – 0.2 0.6
Australia – – – – – – – – – –
Austria – – – – – – – – – –
Azerbaijan – – – – 2.1 x 3.1 x – – – –
Bahamas – – 21.1 31.0 – – – – – –
Bahrain – – – – – – – – – –
Bangladesh 28.3 25.2 32.9 77.5 – 12 y – – – –
Barbados – – – – – 65.6 – – – 9.7
Belarus 90.3 92.3 88.1 – 52.8 50.8 – – 14.7 15.1
Belgium – – – – – – – – – –
Belize 43.9 – 33.9 – 43.5 39.7 68.7 – 7.0 12.9
Benin >95 64.9 44.1 – 14.4 14.1 26.2 38.7 3.5 6.3
Bhutan – – – – – 21.9 x – – – 3.4 x
Bolivia (Plurinational State of) >95 – 40.1 – 23.8 x 20.0 x 44.2 x – 1.4 x –
Bosnia and Herzegovina – – – – 41 42.3 – – 0.0 0.0
Botswana >95 76.5 37.9 63.3 – – – – – –
Brazil – – – – – – – – – –
British Virgin Islands – – – – – – – – – –
Brunei Darussalam – – – – – – – – – –
Bulgaria – – – – – – – – – –
Burkina Faso >95 16.7 21.0 – 30.8 x 29 px 76.4 x 57.3 x 4.0 x 7.9 x
Burundi 79.7 – 30.4 – 50.2 46.3 – – 8.0 13.2
Cabo Verde – – – – – – – – – –
Cambodia 85.1 45.7 91.6 – 42.4 32.7 – – 2.9 6.7
Cameroon 80.0 61.3 23.8 26.6 29.8 x 25.7 x 69.6 x 52 x 1.9 x 3 x
Canada – – – – – – – – – –
Central African Republic 70.7 24.3 23.4 87.8 26.4 x 17.1 x 49.8 x 28.1 x 6.8 x 14.6 x
Chad 55.8 – 16.3 – 11.6 10.2 – 53.6 p 1.5 5.3
Chile >95 81.2 55.5 – – – – – – –
China – – – – – – – – – –
Colombia 21.3 30.7 40.6 – 25.9 27.7 65.9 44.7 – 8.1 x
Comoros – – – – 20.6 17.8 50.7 – 2.5 1.8
Congo 25.0 1.9 25.5 – 41.9 26 54.7 48.9 3.8 7.4
Cook Islands – – – – – – – – – –
Costa Rica – – – – – 29.1 x – 58.6 px – 9.4 x
Côte d'Ivoire 89.8 56.3 40.0 – 31.5 24.4 72.7 30.4 7.9 16.3
Croatia – – – – – – – – – –
Cuba >95 >95 33.8 >95 47.9 59.2 – 79.2 p 15.5 18.7
Cyprus – – – – – – – – – –
Czechia – – – – – – – – – –
Democratic People's Republic of
– – – – – – – – – –
Korea
Democratic Republic of the Congo 43.9 19.7 24.9 – 20.3 17.1 17.3 12.1 1.4 4.5
Denmark – – – – – – – – – –
Djibouti 29.6 3.4 10.1 24.0 – – – – – –
Dominica – – <1 – 39.3 x 49.2 x 73.5 x 85.7 x – –
Dominican Republic 84.2 67.7 54.6 – 39.2 39.4 67.4 40.3 5.3 11.6
Ecuador >95 – 82.3 – – – – – – –
Egypt 16.3 12.7 39.0 – 2.8 y – – – –
El Salvador 39.7 37.1 24.3 – 25.1 25.1 – 30.9 p – 7.5
Equatorial Guinea 50.1 – 14.4 – – – – – – –
Eritrea 47.9 20.2 37.2 – 31.9 x 22.3 x – – – –
Estonia – – – – – – – – – –
Eswatini 79.2 78.0 75.7 83.6 44.4 44.5 92.4 px – 30.4 40.8
Ethiopia 91.7 60.8 59.3 – 37.6 24.0 56.9 p – 8.9 12.4
 S TAT I S T I C A L TA B L E S » 2 13

TABLE 6. HIV/AIDS: INTERVENTION COVERAGE

Comprehensive knowledge of HIV Condom use among adolescents Adolescents age 15–19 tested for
Pregnant Children living with HIV among adolescents age 15–19 age 15–19 with multiple partners HIV in the last 12 months and
women living receiving ART (%) (%) (%) received results (%)
with HIV Early infant 2018 2012–2018* 2012–2018* 2012–2018*
Countries receiving ARVs HIV diagnosis
for PMTCT (%) (%) children adolescents
and areas 2018 2018 0–14 10–19 male female male female male female

Fiji – – – – – – – – – –
Finland – – – – – – – – – –
France – – – – – – – – – –
Gabon 71.6 17.4 57.1 – 34.8 28.8 77.3 58.3 6.1 20.4
Gambia 67.6 28.2 29.5 – 26.5 21.9 – – 1.9 5.9
Georgia – – – – – – – – – 1.6 x
Germany – – – – – – – – – –
Ghana 78.9 58.2 19.9 – 24.5 18.1 24.4 x 21.6 p 1.3 4.5
Greece – – – – – – – – – –
Grenada >95 >95 36.4 – 66.7 x 58.5 x 80.0 x 92.3 x – –
Guatemala 34.5 23.5 36.4 38.6 17.5 19.8 66.3 38 p 2.3 4.8
Guinea 65.0 15.0 20.3 – 27.2 14.0 46.2 p 17.9 0.9 4.7
Guinea-Bissau 47.7 26.7 6.1 – 19.3 20.3 59.5 40.9 1.8 4.8
Guyana 89.3 61.2 37.5 – 33.2 47.6 82.6 p – 10.1 15.8
Haiti 83.4 46.1 39.5 39.7 33.5 36.2 72.5 42.3 6.2 12.2
Holy See – – – – – – – – – –
Honduras 58.7 44.5 40.5 – – – 72.6 38.9 2.8 9.6
Hungary – – – – – – – – – –
Iceland – – – – – – – – – –
India – – – – 28.2 18.5 29.9 35.3 p 0.7 1.9
Indonesia 15.4 1.2 22.1 – 4.0 py 9.4 – – – –
Iran (Islamic Republic of) 80.9 39.8 58.3 28.8 – – – – – –
Iraq – – – – – 5.1 – – – 0.7
Ireland – – – – – – – – – –
Israel – – – – – – – – – –
Italy – – – – – – – – – –
Jamaica >95 – 50.9 62.6 33.7 39.1 75.2 55.9 p 20.0 34.7
Japan – – – – – – – – – –
Jordan – – – – 7.7 y 1.9 y – – – –
Kazakhstan 59.4 51.5 >95 >95 29.5 19.6 93.6 px – 13.8 x 10.9
Kenya 91.2 67.3 60.7 – 57.7 49.0 64.1 26.1 p 26.6 35.3
Kiribati – – – – – – – – – –
Kuwait – – – – – – – – – –
Kyrgyzstan 88.1 82.1 >95 >95 18.3 17.0 – – 0.9 10.5
Lao People's Democratic Republic 35.4 12.7 39.7 – 21.2 19.1 57.2 27.4 p 0.5 1.0
Latvia – – – – – – – – – –
Lebanon – – – – – – – – – –
Lesotho 77.2 69.5 70.0 – 29.7 34.8 79.7 57.9 p 24.9 40.5
Liberia 93.2 14.7 18.2 – 19.0 34.6 21.6 p 27.1 3.6 13.1
Libya 62.7 45.1 32.6 – – – – – – –
Liechtenstein – – – – – – – – – –
Lithuania – – – – – – – – – –
Luxembourg – – – – – – – – – –
Madagascar 25.0 – 4.7 – 24 20.9 5.2 5.5 p 0.8 2.0
Malawi >95 >95 61.0 – 43.1 38.9 59.1 44 22 31.9
Malaysia >95 >95 93.9 – – – – – – –
Maldives – – – – 21.3 26.9 – – 1.8 2.7
Mali 23.7 13.8 18.0 – 26.7 20.7 47.0 25.7 1.6 5.0
Malta – – – – – – – – – –
Marshall Islands – – – – – – – – – –
Mauritania 37.5 – 54.3 66.5 7.4 7.0 – – 1.0 2.4
Mauritius >95 75.3 44.9 – – – – – – –
Mexico – – – >95 – 27.6 – 36.3 p – 6.9
Micronesia (Federated States of) – – – – – – – – – –
Monaco – – – – – – – – – –
Mongolia – – – – 17.3 17.5 77.8 p – 4.6 6.5
Montenegro – – – – 35.2 42.3 64.4 p – 0.0 0.4
Montserrat – – – – – – – – – –
Morocco 61.0 – >95 – – 12.2 x – – – –
Mozambique >95 66.4 60.2 – 28.0 27.7 38.6 43.2 p 10.1 25.3
Myanmar 79.7 25.0 80.1 – 14.3 13.4 – – 2.0 0.9
Namibia >95 – 77.9 >95 61.0 55.9 75.1 p 61.4 p 13.9 28.5
Nauru – – – – – – – – – –
 2 14 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 6. HIV/AIDS: INTERVENTION COVERAGE

Comprehensive knowledge of HIV Condom use among adolescents Adolescents age 15–19 tested for
Pregnant Children living with HIV among adolescents age 15–19 age 15–19 with multiple partners HIV in the last 12 months and
women living receiving ART (%) (%) (%) received results (%)
with HIV Early infant 2018 2012–2018* 2012–2018* 2012–2018*
Countries receiving ARVs HIV diagnosis
for PMTCT (%) (%) children adolescents
and areas 2018 2018 0–14 10–19 male female male female male female

Nepal 50.7 70.8 91.2 – 24.3 18.3 – – 3.0 2.5

Netherlands – – – – – – – – – –
New Zealand – – – – – – – – – –
Nicaragua 90.4 77.2 54.7 – – 16.4 x – – – –
Niger 57.7 7.7 52.5 40.3 20.3 11.2 – – 1.5 4.1
Nigeria 43.6 18.1 35.0 34.2 24.8 28.1 62.0 42.7 7.3 7.9
Niue – – – – – – – – – –
North Macedonia – – – – – – – – – –
Norway – – – – – – – – – –
Oman – – – – – – – – – –
Pakistan 10.0 1.9 11.2 9.6 0.2 y 1.0 y – – 0.0 py 0.2 y
Palau – – – – – – – – – –
Panama 92.1 90.1 75.8 >95 – – – – – –
Papua New Guinea 78.6 74.6 49.2 – – – – – – –
Paraguay 87.5 59.8 43.0 27.7 – 24.9 – 61.0 – 9
Peru 84.6 82.2 47.6 >95 – – – – – –
Philippines 18.5 3.6 20.3 5.8 – 15.7 34.3 px – – 0.3
Poland – – – – – – – – – –
Portugal – – – – – – – – – –
Qatar – – – – 22.8 9.7 – – – –
Republic of Korea – – – – – – – – – –
Republic of Moldova 72.6 74.2 40.4 59.8 25.6 35.2 – – 6.4 9.9
Romania >95 – >95 – – – – – – –
Russian Federation – – – – – – – – – –
Rwanda >95 82.5 63.2 – 59.5 61.6 – – 21.9 27.4
Saint Kitts and Nevis 50.0 – <1 25.0 55.2 x 54.4 x 53.8 x 50.0 x – –
Saint Lucia – 71.4 5.6 – – 57.7 – – – 11.9
Saint Vincent and the Grenadines – – 36.4 – – – – – – –
Samoa – – – – – – – – – –
San Marino – – – – – – – – – –
Sao Tome and Principe – >95 62.2 30.8 42.0 40.5 78.5 – 8.0 22.1
Saudi Arabia – – – – – – – – – –
Senegal 65.1 23.8 30.7 – 25.7 20.3 49.1 p – 1.5 6.1
Serbia – – – – 43.0 x 52.9 x 62.8 x – 1.3 x 1.3 x
Seychelles – – – – – – – – – –
Sierra Leone – – 16.9 – 26.0 24.8 8.8 11.5 3.0 7.4
Singapore – – – – – – – – – –
Slovakia – – – – – – – – – –
Slovenia – – – – – – – – – –
Solomon Islands – – – – – – – – – –
Somalia 19.4 – 14.3 – – – – – – –
South Africa 86.5 88.7 63.0 – 35.5 38.3 87.9 54.8 28.7 38.4
South Sudan 56.0 5.7 8.9 – – 8.3 x – 6.1 px – 3.2 x
Spain – – – – – – – – – –
Sri Lanka – – – – – – – – – –
State of Palestine – – – – – 4.7 – – – –
Sudan 5.1 – 14.7 – 9.8 7.7 – – – 0.6
Suriname >95 – 71.6 >95 – 40.3 x – – – 11.4 x
Sweden – – – – – – – – – –
Switzerland – – – – – – – – – –
Syrian Arab Republic – – – – – – – – – –
Tajikistan 46.5 29.1 >95 – 9.4 x 8.5 – – – 2.1
Thailand >95 >95 82.6 84.8 45.0 46.5 – – 3.5 6.3
Timor-Leste – – – – 12.7 5.9 – – 0.3 0.0
Togo 80.3 46.0 33.6 – 27.9 22.8 – 46.5 px 6.7 11.2
Tokelau – – – – – – – – – –
Tonga – – – – – – – – – –
Trinidad and Tobago – – – – – 55.3 x – – – 10.0 x
Tunisia – – – – 12.2 13.0 – – 0.0 0.3
Turkey – – – – – – – – – –
Turkmenistan – – – – – 18.6 – – – 4.8
Turks and Caicos Islands – – – – – – – – – –
Tuvalu – – – – – – – – – –
 S TAT I S T I C A L TA B L E S » 2 15

TABLE 6. HIV/AIDS: INTERVENTION COVERAGE

Comprehensive knowledge of HIV Condom use among adolescents Adolescents age 15–19 tested for
Pregnant Children living with HIV among adolescents age 15–19 age 15–19 with multiple partners HIV in the last 12 months and
women living receiving ART (%) (%) (%) received results (%)
with HIV Early infant 2018 2012–2018* 2012–2018* 2012–2018*
Countries receiving ARVs HIV diagnosis
for PMTCT (%) (%) children adolescents
and areas 2018 2018 0–14 10–19 male female male female male female

Uganda 92.9 44.8 65.7 – 40.2 40.7 52.1 26.0 28.4 39.4
Ukraine >95 65.0 >95 – 36.6 42.6 89.8 – 9.9 6.9
United Arab Emirates – – – – – – – – – –
United Kingdom – – – – – – – – – –
United Republic of Tanzania 93.3 46.9 65.0 56.2 41.9 36.8 45.2 37.7 13.1 20.8
United States – – – – – – – – – –
Uruguay >95 75.0 63.9 – – 36.4 – 66.8 p – 7.2
Uzbekistan 35.4 31.3 92.8 >95 – – – – – –
Vanuatu – – – – – – – – – –
Venezuela (Bolivarian Republic of) – – – – – – – – – –
Viet Nam 81.0 50.8 91.7 – – 50.5 – – – 3.8
Yemen 12.8 – 33.0 – – – – – – –
Zambia >95 71.4 78.7 – 42.3 38.9 37.7 33 14.9 28.8
Zimbabwe 93.9 63.0 76.4 88.9 48.7 51.4 71.1 – 19.9 29.1

SUMMARY
East Asia and Pacific 55.0 36.9 60.8 – – – – – – –
Europe and Central Asia – – – – – – – – – –
Eastern Europe and Central Asia – – – – – – – – – –
Western Europe – – – – – – – – – –
Latin America and Caribbean 78.6 48.5 46.0 – – – – – – –
Middle East and North Africa 53.2 35.5 73.1 – – – – – – –
North America – – – – – – – – – –
South Asia 56.2 30.8 91.1 – 23.6 15.2 29.9 35.3 0.6 1.7
Sub-Saharan Africa 84.4 60.4 52.0 – 31.1 28.0 51.3 32.9 10.3 15.0
Eastern and Southern Africa 91.5 68.8 61.2 – 37.6 33.0 53.6 33.2 15.8 21.9
West and Central Africa 58.8 29.3 28.4 – 23.6 22.2 48.6 32.6 4.5 7.1
Least developed countries 88.5 49.8 51.0 – 27.7 21.5 41.4 – 7.2 11.6
World 82.4 58.7 54.2 – 24.1 20.3 – – – 6.7
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES

Pregnant women living with HIV receiving ARVs for
PMTCT – Percentage of the estimated number of pregnant
women living with HIV who received effective regimens
(excluding single-dose nevirapine) of antiretroviral medicines
(ARVs) for prevention of mother-to-child transmission
(PMTCT) of HIV.
Early infant HIV diagnosis – Percentage of HIV-exposed
infants who received a virologic test for HIV within two
months of birth.
Children living with HIV receiving ART – Percentage of
children living with HIV who received antiretroviral therapy
(ART).
Comprehensive knowledge of HIV among adolescents
age 15–19 – Percentage of adolescents aged 15–19 who
correctly identify the two ways of preventing the sexual
transmission of HIV, who know that a healthy-looking person
can be HIV-positive and who reject the two most common
misconceptions about HIV transmission.
Condom use among adolescents age 15–19 with
multiple partners – Percentage of adolescents aged 15-19
who had more than one sexual partner in the past 12 months
reporting the use of a condom during their last sexual
intercourse.
Adolescents age 15–19 tested for HIV in the last 12
months and received results – Percentage of adolescents
aged 15-19 who have been tested for HIV in the last 12 months
and received the result of the last test.
Pregnant women living with HIV
receiving ARVs for PMTCT – Global
AIDS Monitoring and UNAIDS 2019
estimates. Last update: July 2019.
Early infant HIV diagnosis – Global
AIDS Monitoring and UNAIDS 2019
estimates. Last update: July 2019.
Children living with HIV receiving
ART – Global AIDS Monitoring and
UNAIDS 2019 estimates. Last update:
July 2019.
Comprehensive knowledge of HIV
among adolescents age 15–19 –
Nationally representative population-
based surveys, including MICS, DHS, AIS,
and other household surveys 2012-2018.
Last update: April 2019.
NOTES
– Data not available.
x Data refer to years or periods other
than those specified in the column
heading. Such data are not included
in the calculation of regional and
global averages. Estimates from
years prior to 2000 are not displayed.
p Based on small denominators
(typically 25–49 unweighted cases).
No data based on fewer than 25
unweighted cases are displayed.
Condom use among adolescents age
15–19 with multiple partners –
Nationally representative population-
based surveys, including MICS, DHS, AIS,
and other household surveys 2012-2018.
Last update: April 2019.
Adolescents age 15–19 tested for HIV
in the last 12 months and received
results – Nationally representative
population-based surveys, including
MICS, DHS, AIS, and other household
surveys 2012-2018. Last update: April
2019.
y Data differ from the standard defini-
tion or refer to only part of a country.
If they fall within the noted reference
period, such data are included in the
calculation of regional and global
averages.
* Data refer to the most recent year
available during the period specified
in the column heading.
TABLE 7. NUTRITION: NEWBORNS, INFANTS AND YOUNG CHILDREN
Infant and Young Child Feeding (0–23 months)
Weight at birth 2013–2018*

Introduction Continued breastfeeding Zero

Early to solid, (12–23 months) Minimum Minimum vegetable or
Low Unweighed at initiation Exclusive semi-solid or (%) Minimum diet meal acceptable fruit
Countries birthweight
(%)
birth
(%)
of breastfeeding soft foods
breastfeeding (<6 months) (6–8 months) Poorest Richest
diversity frequency diet consumption
(6–23 months) (6–23 months) (6–23 months) (6–23 months)
and areas 2015 2010–2018* (%) (%) (%) All children 20% 20% (%) (%) (%) (%)

Afghanistan – 86 63 58 61 74 80 70 22 51 15 59
Albania 5 13 57 37 89 43 38 37 52 51 29 26
Algeria 7 11 36 x 25 x 77 x 36 x 35 x 34 x – 52 x – –
Andorra 7 14 – – – – – – – – – –
Angola 15 45 48 37 79 67 74 53 29 33 13 36
Anguilla – – – – – – – – – – – –
Antigua and Barbuda 9 – – – – – – – – – – –
Argentina 7 4 53 x 32 x 97 x 39 x 49 x 33 x – 68 x – –
Armenia 9 0 41 44 90 29 32 24 36 72 24 22
Australia 7 1 – – – – – – – – – –
Austria 7 0 – – – – – – – – – –
Azerbaijan 7 3 20 12 77 26 x 24 x 15 x 35 x – – 38 x
Bahamas 13 16 – – – – – – – – – –
Bahrain 12 2 – – – – – – – – – –
Bangladesh 28 68 51 55 65 92 94 85 27 64 23 53
Barbados – 2 40 x 20 x 90 x 41 x – x,p – x,p – 61 x – –
Belarus 5 0 53 x 19 x 95 x 17 x 26 x 19 x – 74 x – –
Belgium 7 4 – – – – – – – – – –
Belize 9 1 68 33 79 47 59 37 58 68 x – 30
Benin 17 40 54 41 56 69 77 52 26 45 15 54
Bhutan 12 28 78 51 87 80 x 88 x 76 x – 63 x – –
Bolivia (Plurinational State of) 7 17 55 58 81 x 55 74 x,r 53 x,r 64 x – – 20 x
Bosnia and Herzegovina 3 2 42 x 18 x 76 x 12 x 16 x 10 x – 72 x – –
Botswana 16 5 53 30 73 15 – – – – – –
Brazil 8 3 43 x 39 x 94 x – – – – – – –
British Virgin Islands – – – – – – – – – – – –
Brunei Darussalam 11 4 – – – – – – – – – –
Bulgaria 10 6 – – – – – – – – – –
Burkina Faso 13 36 56 48 75 90 x 93 x 77 x 5 x 57 3 x 75 x
Burundi 15 20 85 82 86 89 92 84 18 39 10 9
Cabo Verde – – 73 x 60 x – – – – – – – –
Cambodia 12 9 63 65 82 58 65 39 40 72 30 35
Cameroon 12 40 31 28 83 46 75 16 23 60 16 42
Canada 6 1 – – – – – – – – – –
Central African Republic 15 39 53 29 94 x 66 x 74 x 57 x 27 x 20 x 9 x 22 x
Chad – 88 23 <1.0 59 79 82 68 9 37 6 70
Chile 6 0 – – – – – – – – – –
China 5 0 29 21 83 – – – 35 69 25 –
Colombia 10 18 72 36 78 45 x 49 x 33 x – 61 – –
Comoros 24 33 34 x 11 x 80 x 65 x 68 x 69 x 22 x 30 x 6 x 52 x
Congo 12 10 25 33 84 32 54 20 14 32 5 51
Cook Islands 3 – – – – – – – – – – –
Costa Rica 7 2 60 x 33 x 90 x 40 x 50 x 13 x – 79 x – –
Côte d'Ivoire 15 25 37 23 65 63 76 36 23 49 14 44
Croatia 5 – – – – – – – – – – –
Cuba 5 5 48 33 91 31 – – 70 79 56 27
Cyprus – 27 – – – – – – – – – –
Czechia 8 0 – – – – – – – – – –
Democratic People's Republic of
– 0 43 71 78 – – – 47 75 29 –
Korea
Democratic Republic of the Congo 11 24 52 47 79 82 87 67 17 35 8 29
Denmark 5 4 – – – – – – – – – –
Djibouti – – 52 x 12 x – – – – – – – –
Dominica – – – – – – – – – – – –
Dominican Republic 11 4 38 5 81 20 27 14 51 80 43 35
Ecuador 11 19 55 x 40 x 74 x – – – – – – –
Egypt – 39 27 40 75 50 58 43 35 60 23 45
El Salvador 10 7 42 47 90 67 71 57 73 87 65 16
Equatorial Guinea – 30 – 7 x – 31 x 47 x,r 34 x,r – 39 x – –
Eritrea – 65 93 x 69 x 44 x 86 x – – – – – –
Estonia 4 0 – – – – – – – – – –
Eswatini 10 9 48 64 90 28 29 19 48 85 38 –
Ethiopia – 86 73 57 60 85 84 83 12 45 7 69
 S TAT I S T I C A L TA B L E S » 2 17
TABLE 7. NUTRITION: NEWBORNS, INFANTS AND YOUNG CHILDREN

Infant and Young Child Feeding (0–23 months)

Weight at birth 2013–2018*

Introduction Continued breastfeeding Zero

Early to solid, (12–23 months) Minimum Minimum vegetable or
Low Unweighed at initiation Exclusive semi-solid or (%) Minimum diet meal acceptable fruit
Countries birthweight
(%)
birth
(%)
of breastfeeding soft foods
breastfeeding (<6 months) (6–8 months) Poorest Richest
diversity frequency diet consumption
(6–23 months) (6–23 months) (6–23 months) (6–23 months)
and areas 2015 2010–2018* (%) (%) (%) All children 20% 20% (%) (%) (%) (%)

Fiji – 11 x 57 x 40 x – – – – – – – –
Finland 4 6 – – – – – – – – – –
France 7 0 – – – – – – – – – –
Gabon 14 9 32 x 5 x 82 x 23 x 34 x 19 x 18 x – – 52 x
Gambia 17 41 52 47 55 78 81 69 10 58 8 76
Georgia 6 0 69 x 55 x 85 x 30 x 31 x 31 x – – – –
Germany 7 2 – – – – – – – – – –
Ghana 14 40 56 52 73 76 92 71 24 43 13 51
Greece 9 4 – – – – – – – – – –
Grenada – – – – – – – – – – – –
Guatemala 11 6 63 53 80 72 85 48 59 82 52 27
Guinea – 49 34 33 54 78 91 r 53 r 6 24 2 85
Guinea-Bissau 21 56 34 53 57 77 83 57 10 57 8 44
Guyana 16 11 49 21 81 46 64 25 40 63 28 33
Haiti – 67 47 40 91 52 59 43 19 39 11 55
Holy See – – – – – – – – – – – –
Honduras 11 17 64 x 31 x 86 x 59 x 76 x 42 x 61 x 86 x 55 x 36 x
Hungary 9 0 – – – – – – – – – –
Iceland 4 8 – – – – – – – – – –
India – z 22 41 55 46 80 88 69 20 36 10 55
Indonesia 10 10 58 51 86 67 74 56 54 72 40 18
Iran (Islamic Republic of) – – 69 x 53 x 76 x – – – – – – –
Iraq – 28 32 26 85 35 47 32 45 78 35 25
Ireland 6 4 – – – – – – – – – –
Israel 8 0 – – – – – – – – – –
Italy 7 2 – – – – – – – – – –
Jamaica 15 4 65 x 24 x 64 x 38 x 39 x 29 x – 42 x – –
Japan 9 5 – – – – – – – – – –
Jordan 14 5 67 25 83 26 28 33 35 62 23 41
Kazakhstan 5 1 83 38 66 41 40 45 49 77 38 21
Kenya 11 34 62 61 80 75 79 69 36 51 22 29
Kiribati – 24 x 80 x 66 x 70 x 85 x 92 x 80 x 27 x – – –
Kuwait 10 30 – – – – – – – – – –
Kyrgyzstan 6 0 81 46 91 47 53 36 60 76 44 14
Lao People's Democratic Republic 17 33 50 44 87 43 66 19 36 70 27 36
Latvia 5 0 – – – – – – – – – –
Lebanon 9 0 41 x – – 14 x – – – – – –
Lesotho 15 17 65 67 83 53 74 26 17 61 11 50
Liberia – 77 61 55 47 69 76 53 10 30 5 39
Libya – – – – – – – – – – – –
Liechtenstein – – – – – – – – – – – –
Lithuania 5 7 – – – – – – – – – –
Luxembourg 7 0 – – – – – – – – – –
Madagascar 17 60 x 66 x 42 x 90 x 79 x 79 x 77 x 22 x – – 33 x
Malawi 14 16 76 59 85 84 87 78 23 29 8 23
Malaysia 11 1 – 40 – – – – – – – –
Maldives 12 11 67 63 97 73 79 – p 71 70 51 15
Mali – 63 53 40 42 79 82 r 73 r 11 23 3 70
Malta 6 0 – – – – – – – – – –
Marshall Islands – 10 61 43 64 36 25 – p 34 61 16 46
Mauritania – 64 68 40 74 70 75 61 28 39 14 51
Mauritius 17 6 – – – – – – – – – –
Mexico 8 2 51 30 82 36 52 16 59 81 48 18
Micronesia (Federated States of) – – – – – – – – – – – –
Monaco 5 0 – – – – – – – – – –
Mongolia 5 1 84 59 97 64 66 58 45 92 41 37
Montenegro 5 1 14 17 95 15 27 11 69 90 61 9
Montserrat – – – – – – – – – – – –
Morocco 17 27 43 35 84 x 35 x 45 x 19 x – – – –
Mozambique 14 49 69 41 95 75 x 80 x 53 x 28 x 41 x 13 x 36 x
Myanmar 12 55 67 51 75 78 84 66 21 58 16 56
Namibia 16 14 71 48 80 47 55 27 25 41 13 52
Nauru – 4 76 x 67 x – 67 x – – – – – –
TABLE 7. NUTRITION: NEWBORNS, INFANTS AND YOUNG CHILDREN

Infant and Young Child Feeding (0–23 months)

Weight at birth 2013–2018*

Introduction Continued breastfeeding Zero

Early to solid, (12–23 months) Minimum Minimum vegetable or
Low Unweighed at initiation Exclusive semi-solid or (%) Minimum diet meal acceptable fruit
Countries birthweight
(%)
birth
(%)
of breastfeeding soft foods
breastfeeding (<6 months) (6–8 months) Poorest Richest
diversity frequency diet consumption
(6–23 months) (6–23 months) (6–23 months) (6–23 months)
and areas 2015 2010–2018* (%) (%) (%) All children 20% 20% (%) (%) (%) (%)

Nepal 22 39 55 65 84 94 97 91 45 71 36 38
Netherlands 6 6 – – – – – – – – – –
New Zealand 6 8 – – – – – – – – – –
Nicaragua 11 8 54 x 32 x 89 x 52 x 64 x 28 x – – – –
Niger – 77 53 x 23 x 62 x 78 x 85 x 71 x 8 x 51 x 6 x 67 x
Nigeria – 75 33 25 66 51 80 r 48 r 34 46 15 32
Niue – – – – – – – – – – – –
North Macedonia 9 4 21 x 23 x 87 x 27 x 25 x 26 x – 65 x – –
Norway 4 3 – – – – – – – – – –
Oman 11 0 82 23 95 – – – – 65 – –
Pakistan – 84 20 47 65 63 75 52 15 63 13 61
Palau – – – – – – – – – – – –
Panama 10 9 47 21 78 41 57 18 – 64 – –
Papua New Guinea – – – 56 x – – – – – – – –
Paraguay 8 2 50 30 87 33 41 43 52 75 40 16
Peru 9 5 50 66 95 65 69 53 83 – – 7
Philippines 20 16 57 33 x 89 x 60 68 49 54 x – – 22 x
Poland 6 0 – – – – – – – – – –
Portugal 9 0 – – – – – – – – – –
Qatar 7 2 34 x 29 x 74 x 47 x – – – 49 x – –
Republic of Korea 6 2 – – – – – – – – – –
Republic of Moldova 5 1 61 x 36 x 75 x 27 x 44 x 22 x 70 x 49 x – 10 x
Romania 8 2 58 x 16 x – – – – – – – –
Russian Federation 6 0 25 x – – – – – – – – –
Rwanda 8 8 80 87 57 91 94 81 28 47 18 25
Saint Kitts and Nevis – – – – – – – – – – – –
Saint Lucia – 0 50 x 3 x – x,p 29 x – x,p – x,p – 50 x – –
Saint Vincent and the Grenadines – – – – – – – – – – – –
Samoa – 24 81 70 74 73 – – – – – –
San Marino 3 2 – – – – – – – – – –
Sao Tome and Principe 7 7 38 72 74 51 65 46 37 60 23 27
Saudi Arabia – – – – – – – – – – – –
Senegal 18 40 34 42 67 70 77 61 20 31 8 52
Serbia 5 2 51 13 97 15 20 18 77 96 70 3
Seychelles 12 0 – – – – – – – – – –
Sierra Leone 14 52 56 47 68 61 71 33 18 43 9 41
Singapore 10 17 – – – – – – – – – –
Slovakia 8 2 – – – – – – – – – –
Slovenia 6 4 – – – – – – – – – –
Solomon Islands – 14 79 76 – 71 – – – – – –
Somalia – 96 x 23 x 5 x 17 x 43 x 61 x 23 x – – – –
South Africa 14 19 67 32 83 34 47 25 40 52 23 37
South Sudan – – 50 x 45 x 42 x 62 x 67 x 58 x – 12 x – –
Spain 8 4 – – – – – – – – – –
Sri Lanka 16 0 90 82 88 91 – – – – – –
State of Palestine 8 0 41 38 90 31 33 29 50 79 39 27
Sudan – 89 69 55 61 73 72 74 24 42 15 67
Suriname 15 19 45 x 3 x 79 x 17 x 16 x 15 x – 64 x – –
Sweden 2 5 – – – – – – – – – –
Switzerland 6 0 – – – – – – – – – –
Syrian Arab Republic – 52 x 46 x 43 x 44 x 45 x 57 x 42 x – – – –
Tajikistan 6 9 62 36 63 57 63 53 23 40 9 58
Thailand 11 1 40 23 85 24 35 11 63 85 54 22
Timor-Leste – 47 75 50 63 52 61 44 28 46 13 35
Togo 16 40 61 57 67 82 92 69 18 46 12 45
Tokelau – – – – – – – – – – – –
Tonga – 6 79 x 52 x – 41 x – – – – – –
Trinidad and Tobago 12 19 46 x 21 x 56 x 34 x 45 x – x,p – 70 x – –
Tunisia 7 3 32 14 97 30 39 28 – 88 55 20
Turkey 11 0 50 30 75 50 – – – – – –
Turkmenistan 5 1 73 58 82 44 54 24 82 93 77 9
Turks and Caicos Islands – – – – – – – – – – – –
Tuvalu – 3 x 15 x 35 x – 53 x – – – – – –
 S TAT I S T I C A L TA B L E S » 2 19
TABLE 7. NUTRITION: NEWBORNS, INFANTS AND YOUNG CHILDREN

Infant and Young Child Feeding (0–23 months)

Weight at birth 2013–2018*

Introduction Continued breastfeeding Zero

Early to solid, (12–23 months) Minimum Minimum vegetable or
Low Unweighed at initiation Exclusive semi-solid or (%) Minimum diet meal acceptable fruit
Countries birthweight
(%)
birth
(%)
of breastfeeding soft foods
breastfeeding (<6 months) (6–8 months) Poorest Richest
diversity frequency diet consumption
(6–23 months) (6–23 months) (6–23 months) (6–23 months)
and areas 2015 2010–2018* (%) (%) (%) All children 20% 20% (%) (%) (%) (%)

Uganda – 33 66 65 81 67 77 53 26 42 15 44
Ukraine 6 3 66 x 20 x 75 x 31 x 31 x 30 x – 64 x – –
United Arab Emirates 13 3 – – – – – – – – – –
United Kingdom 7 4 – – – – – – – – – –
United Republic of Tanzania 10 36 51 59 92 72 75 70 21 40 9 29
United States 8 2 – 35 – 13 – – – – – –
Uruguay 8 6 77 – – – – – – – – –
Uzbekistan 5 1 x 67 x 24 x 47 x 57 x 66 x 52 x – – – –
Vanuatu 11 13 85 73 72 58 – – – – – –
Venezuela (Bolivarian Republic of) 9 – – – – – – – – – – –
Viet Nam 8 6 26 24 91 43 55 29 59 91 55 14
Yemen – 92 53 10 69 63 73 56 21 59 15 66
Zambia 12 34 66 70 82 63 87 r 48 r 18 42 10 35
Zimbabwe 13 18 58 47 91 55 61 45 23 36 8 32

SUMMARY
East Asia and Pacific 8 6 38 30 84 60 q 68 q 47 q 40 71 30 23 q
Europe and Central Asia 7 2 – – – – – – – – – –
Eastern Europe and Central
7 2 57 q 33 q 75 q 47 q – – – – – –
Asia
Western Europe 7 3 – – – – – – – – – –
Latin America and Caribbean 9 7 54 q 38 q 84 q 45 q 57 q 28 q 60 q 75 q – 21 q
Middle East and North Africa 11 35 36 30 78 47 55 42 36 65 26 42
North America 8 2 – 35 – 13 – – – – – –
South Asia 27 39 40 54 52 78 86 67 20 44 12 55
Sub-Saharan Africa 14 52 52 44 72 67 79 59 24 43 12 42
Eastern and Southern Africa 14 48 65 55 77 72 77 65 24 43 13 44
West and Central Africa 14 54 41 34 68 64 82 53 25 42 12 40
Least developed countries 16 54 58 51 72 78 82 69 21 45 13 49
World 15 29 44 42 69 65 78 58 29 53 19 44
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES

Low birthweight – Percentage of infants weighing less than
2,500 grams at birth.
Unweighed at birth – Percentage of births without a
birthweight in the data source; Note that (i) estimates from
household surveys include live births among women age 15–49
years in the survey reference period (e.g. last 2 years) for which
a birthweight was not available from an official document (e.g.
health card) or could not be recalled by the respondent at the
time of interview and may have been recalculated to count
birthweights <250g and >5500g as missing and (ii) estimates
from administrative sources (e.g. Health Management
Information Systems) were calculated using numerator data
from the country administrative source and denominator data
were the number of annual births according to the United
Nations Population Division World Population Prospects, 2017
edition. These estimates include unweighed births and
weighed births not recorded in the system.
Early initiation of breastfeeding – Percentage of children
born in the last 24 months who were put to the breast within
one hour of birth.
Exclusive breastfeeding (<6 months) – Percentage of
infants 0–5 months of age who were fed exclusively with
breastmilk during the previous day.
Continued breastfeeding (12–23 months) – Percentage of
children 12–23 months of age who were fed with breastmilk
during the previous day.
Introduction of solid, semi-solid or soft foods (6–8
months) – Percentage of infants 6–8 months of age who were
fed with solid, semi-solid or soft food during the previous day.
Minimum Diet Diversity (6–23 months) – Percentage of
children 6-23 months of age who received foods from at least 5
out of 8 defined food groups during the previous day.
Minimum Meal Frequency (6–23 months) – Percentage of
children 6–23 months of age who received solid, semi-solid, or
soft foods (but also including milk feeds for non-breastfed
children) the minimum number of times or more during the
previous day.
Minimum Acceptable Diet (6–23 months) – Percentage of
children 6–23 months of age who received a minimum
acceptable diet during the previous day.
Zero vegetable or fruit consumption (6–23 months) –
Percentage of children 6–23 months of age who did not
consume any vegetables or fruits during the previous day.
Low birthweight – Modelled estimates Infant and young child feeding (0–23
from UNICEF and WHO. Last update: May months) – DHS, MICS and other national
2019. household surveys. Last update: June
Unweighed at birth – Demographic and 2019.
Health Surveys (DHS), Multiple Indicator
Cluster Surveys (MICS), other national
household surveys, data from routine
reporting systems. Last update: June
2019.
NOTES
– Data not available. r Disaggregated data are from different
sources than the data presented for
x Data refer to years or periods other
than those specified in the column all children for the same indicator.
heading. Such data are not included z The estimate is based on partial data
in the calculation of regional and for the most recent survey, therefore
global averages. Estimates from modeled estimates are not shown
years prior to 2000 are not displayed. for the individual country but have
p Based on small denominators been used in regional and global
(typically 25-49 unweighted cases). estimates.
No data based on fewer than 25 * Data refer to the most recent year
unweighted cases are displayed. available during the period specified
q Regional estimates for East Asia and in the column heading.
Pacific exclude China, Latin America
and the Caribbean exclude Brazil,
Eastern Europe and Central Asia
exclude the Russian Federation.
 220 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 8. NUTRITION: PRESCHOOL/SCHOOL AGE CHILDREN, WOMEN AND HOUSEHOLDS

Malnutrition among
Malnutrition among preschool-aged children school-aged children Malnutrition among
(0–4 years of age) (5–19 years of age) women
2013–2018* 2016 2016
Vitamin A
Stunted (%) Overweight supplemen- Overweight Underweight Anaemia 15–49 Percentage of
(moderate and severe) Wasted (%) (%) tation, full Thinness (%) (%) 18+ years (%) years (%) households
Countries moderate and moderate
coverage
(%) thin and overweight BMI mild, moderate
consuming
iodized salt
and areas all children poorest 20% richest 20% severe severe and severe 2017 severely thin and obese <18.5 kg/m2 and severe 2013–2018*

Afghanistan 41 49 31 4 10 5 95 f 17 9 16 42 57
Albania 11 17 9 1 2 16 – 1 25 2 25 65
Algeria 12 13 x 11 x 1 x 4 x 12 x – 6 31 4 36 81
Andorra – – – – – – – 1 36 1 14 –
Angola 38 47 20 1 5 3 3 f 8 11 11 48 82
Anguilla – – – – – – – – – – – –
Antigua and Barbuda – – – – – – – 3 27 4 22 –
Argentina 8 x – – <1 x 1 x 10 x – 1 37 1 19 –
Armenia 9 12 6 2 4 14 – 2 19 3 29 99
Australia 2 x – – <1 x <1 x 8 x – 1 34 2 9 –
Austria – – – – – – – 2 27 3 17 –
Azerbaijan 18 28 16 1 3 14 41 f,w 3 19 3 38 93
Bahamas – – – – – – – 3 36 3 23 –
Bahrain – – – – – – – 6 35 4 42 –
Bangladesh 36 49 20 3 14 2 99 f 18 9 22 40 68
Barbados 8 8 x 3 x 2 x 7 x 12 x – 4 28 3 22 37 x
Belarus 4 x 10 x 2 x 1 x 2 x 10 x – 2 23 2 23 –
Belgium – – – – – – – 1 24 2 16 –
Belize 15 26 5 1 2 7 – 3 29 3 22 85
Benin 32 46 18 1 5 2 99 f 7 11 9 47 85
Bhutan 34 x 41 x 21 x 2 x 6 x 8 x – f 16 10 11 36 –
Bolivia (Plurinational State of) 16 32 x,r 9 x,r 1 2 10 31 f 1 28 2 30 86
Bosnia and Herzegovina 9 10 x 10 x 2 x 2 x 17 x – 2 21 2 29 –
Botswana 31 x – – 3 x 7 x 11 x 83 f 6 18 7 30 83 x
Brazil 7 x – – <1 x 2 x 6 x – 3 28 3 27 98 x
British Virgin Islands – – – – – – – – – – – –
Brunei Darussalam 20 x – – <1 x 3 x 8 x – 6 27 6 17 –
Bulgaria 9 w,x – – 1 w,x 3 w,x 14 w,x – 2 29 2 26 92 x,y
Burkina Faso 21 42 x,r 19 x,r 2 9 2 0 f 8 8 13 50 92 x
Burundi 56 69 31 1 5 1 79 f 7 10 12 27 89
Cabo Verde – – – – – – – 7 12 8 33 97 x,y
Cambodia 32 42 19 2 10 2 73 f 11 11 14 47 68
Cameroon 32 42 14 1 5 7 9 f 6 13 7 41 86
Canada – – – – – 10 x,y – 1 32 2 10 –
Central African Republic 40 45 x 30 x 2 x 8 x 2 x 0 f 8 11 13 46 84 x
Chad 40 41 31 4 13 3 67 f 8 9 14 48 77
Chile 2 – – – <1 9 – 1 35 1 15 –
China 8 – – 1 x 2 9 – 3 29 6 26 96 b,y
Colombia 13 x 19 x 6 x <1 x 1 x 5 x – 2 24 3 21 –
Comoros 31 39 x 24 x 4 x 11 x 11 x 21 f 7 12 9 29 82 x
Congo 21 30 14 3 8 6 12 f 7 11 12 52 91
Cook Islands – – – – – – – <1 63 <1 – –
Costa Rica 6 x – – – 1 x 8 x – 2 32 2 15 –
Côte d'Ivoire 22 30 9 1 6 1 94 f 6 13 8 53 80
Croatia – – – – – – – 1 28 2 27 –
Cuba 7 x – – – 2 x – – 3 30 4 25 –
Cyprus – – – – – – – 1 33 2 25 –
Czechia 3 x – – 1 x 5 x 4 x – 2 28 1 26 –
Democratic People's Republic of
19 – – 1 3 2 90 f 5 23 8 32 –
Korea
Democratic Republic of the Congo 43 49 23 3 8 4 1 f 9 10 14 41 82
Denmark – – – – – – – 1 25 3 16 –
Djibouti 34 41 x 23 x 9 x 22 x 8 x – f 6 17 8 33 4 x
Dominica – – – – – – – 3 33 3 24 –
Dominican Republic 7 12 4 1 2 8 – 3 33 4 30 30 x
Ecuador 24 37 x,r 14 x,r 1 2 8 – 1 28 2 19 –
Egypt 22 25 24 5 9 16 – f 3 37 1 29 93
El Salvador 14 24 5 <1 2 6 – 2 30 3 23 –
Equatorial Guinea 26 x 28 x 19 x 2 x 3 x 10 x 5 f 8 11 10 44 57 x
Eritrea 52 x 59 x 29 x 4 x 15 x 2 x – f,z 8 11 17 38 86 x
Estonia – – – – – – – 2 21 2 26 –
Eswatini 26 30 9 <1 2 9 33 f 4 17 6 27 90
 S TAT I S T I C A L TA B L E S » 2 2 1

TABLE 8. NUTRITION: PRESCHOOL/SCHOOL AGE CHILDREN, WOMEN AND HOUSEHOLDS

Malnutrition among
Malnutrition among preschool-aged children school-aged children Malnutrition among
(0–4 years of age) (5–19 years of age) women
2013–2018* 2016 2016
Vitamin A
Stunted (%) Overweight supplemen- Overweight Underweight Anaemia 15–49 Percentage of
(moderate and severe) Wasted (%) (%) tation, full Thinness (%) (%) 18+ years (%) years (%) households
Countries moderate and moderate
coverage
(%) thin and overweight BMI mild, moderate
consuming
iodized salt
and areas all children poorest 20% richest 20% severe severe and severe 2017 severely thin and obese <18.5 kg/m2 and severe 2013–2018*

Ethiopia 38 45 26 3 10 3 77 f 10 9 15 23 86
Fiji 8 x – – 2 x 6 x 5 x – 4 34 2 31 –
Finland – – – – – – – 1 27 1 16 –
France – – – – – – – 1 30 3 18 –
Gabon 17 31 x 6 x 1 x 3 x 8 x 0 f 6 16 7 59 89 x
Gambia 25 29 15 4 11 3 32 f 7 12 10 58 69
Georgia 11 x 22 x 8 x 1 x 2 x 20 x – 3 20 3 27 >99 x,y
Germany 1 x – – <1 x 1 x 4 x – 1 26 1 16 –
Ghana 19 25 8 1 5 3 50 f 6 11 7 46 64
Greece – – – – – – – 1 37 1 16 –
Grenada – – – – – – – 4 26 4 23 –
Guatemala 47 66 17 <1 1 5 26 f,w 1 29 2 16 88 x
Guinea 32 39 18 3 8 4 64 f 7 10 11 51 73
Guinea-Bissau 28 31 15 1 6 2 95 f 7 11 9 44 26
Guyana 11 20 7 2 6 5 – 5 25 5 32 43
Haiti 22 34 9 1 4 3 17 f 4 28 6 46 8
Holy See – – – – – – – – – – – –
Honduras 23 42 x 8 x <1 x 1 x 5 x – 2 27 3 18 –
Hungary – – – – – – – 2 28 2 26 –
Iceland – – – – – – – 1 28 2 16 –
India 38 51 22 8 21 2 – f,z 27 7 24 51 93
Indonesia 36 48 29 7 14 12 62 f 10 15 12 29 92 b,y
Iran (Islamic Republic of) 7 x – – 1 x 4 x – – 9 26 4 30 –
Iraq 22 x 24 x 21 x 3 x 6 x 11 x – 5 32 3 29 68
Ireland – – – – – – – <1 31 1 15 –
Israel – – – – – – – 1 35 1 16 –
Italy – – – – – – – 1 37 1 17 –
Jamaica 6 – – 1 4 8 – 2 30 4 23 –
Japan 7 x – – <1 x 2 x 2 x – 2 14 10 22 –
Jordan 8 14 x 2 x 1 x 2 x 5 x – 4 31 2 35 88 b,x,y
Kazakhstan 8 10 6 1 3 9 – f 2 20 4 31 94
Kenya 26 36 14 1 4 4 44 f 8 11 10 27 95
Kiribati – – – – – – 37 f <1 55 1 26 –
Kuwait 5 – – 1 3 6 x,y – 4 42 1 24 –
Kyrgyzstan 13 18 11 1 3 7 – f 3 16 4 36 99
Lao People's Democratic Republic 44 x 61 x 20 x 2 x 6 x 2 x 57 f 9 14 12 40 94
Latvia – – – – – – – 2 22 2 25 –
Lebanon 17 x – – 3 x 7 x 17 x – 5 33 3 31 95 x
Lesotho 33 46 13 1 3 7 18 f 5 15 5 27 85
Liberia 32 36 20 2 6 3 97 f 7 10 8 35 91
Libya 21 x – – 3 x 7 x 22 x – 6 33 2 33 69 x
Liechtenstein – – – – – – – – – – – –
Lithuania – – – – – – – 3 21 1 26 –
Luxembourg – – – – – – – 1 26 2 16 –
Madagascar 49 39 47 1 8 1 87 f 7 11 15 37 68 x
Malawi 37 46 25 1 3 5 91 f 6 11 9 34 78
Malaysia 21 – – – 12 6 – 7 27 7 25 28 x,y
Maldives 19 x 22 x 15 x 3 x 11 x 6 x 69 f 14 17 9 43 97 x
Mali 30 41 15 3 13 2 9 f 8 11 10 51 90
Malta – – – – – – – 1 37 1 16 –
Marshall Islands 35 44 20 1 4 4 – f <1 59 1 27 –
Mauritania 28 36 19 4 15 1 0 f 8 13 8 37 8
Mauritius – – – – – – – 7 15 7 25 –
Mexico 10 16 7 <1 2 5 – f 2 35 2 15 –
Micronesia (Federated States of) – – – – – – – f <1 51 2 23 –
Monaco – – – – – – – <1 <1 <1 – –
Mongolia 7 14 3 <1 1 12 83 f 2 18 3 19 80
Montenegro 9 5 9 1 3 22 – 2 25 2 25 –
Montserrat – – – – – – – – – – – –
Morocco 15 x 28 x 7 x 1 x 2 x 11 x 99 f,w 6 27 3 37 43 x
Mozambique 43 x 51 x 24 x 2 x 6 x 8 x 61 f 4 13 10 51 42 x
Myanmar 29 38 16 1 7 2 89 f 13 12 14 46 81
 222 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 8. NUTRITION: PRESCHOOL/SCHOOL AGE CHILDREN, WOMEN AND HOUSEHOLDS

Malnutrition among
Malnutrition among preschool-aged children school-aged children Malnutrition among
(0–4 years of age) (5–19 years of age) women
2013–2018* 2016 2016
Vitamin A
Stunted (%) Overweight supplemen- Overweight Underweight Anaemia 15–49 Percentage of
(moderate and severe) Wasted (%) (%) tation, full Thinness (%) (%) 18+ years (%) years (%) households
Countries moderate and moderate
coverage
(%) thin and overweight BMI mild, moderate
consuming
iodized salt
and areas all children poorest 20% richest 20% severe severe and severe 2017 severely thin and obese <18.5 kg/m2 and severe 2013–2018*

Namibia 23 31 9 3 7 4 27 f 8 15 9 23 74
Nauru 24 x 52 x 18 x <1 x 1 x 3 x – <1 65 <1 – –
Nepal 36 48 18 2 10 1 81 f 16 8 17 35 94
Netherlands – – – – – – – 1 25 2 16 –
New Zealand – – – – – – – <1 40 2 12 –
Nicaragua 17 35 x 6 x 1 x 2 x 8 x – f 2 29 3 16 –
Niger 41 47 x,r 35 x,r 2 10 1 53 f 10 8 13 49 59
Nigeria 44 63 18 3 11 2 83 f 10 8 10 50 93 x
Niue – – – – – – – <1 59 1 – –
North Macedonia 5 x 7 x 2 x <1 x 2 x 12 x – 2 26 2 23 –
Norway – – – – – – – 1 27 2 15 –
Oman 14 – – 2 8 4 – 7 32 5 38 88
Pakistan 38 56 22 2 7 3 92 f 19 10 15 52 69 x,y
Palau – – – – – – – <1 64 1 – –
Panama 19 x – – <1 x 1 x 10 x – 2 29 3 23 –
Papua New Guinea 49 x – – 6 x 14 x 14 x – f 1 32 3 37 60 x
Paraguay 6 12 1 <1 1 12 – 2 28 3 23 93 x
Peru 13 29 5 <1 1 8 – 1 27 2 18 89
Philippines 33 49 15 2 x 7 4 – f 10 13 14 16 52 y
Poland 3 – – – – – – 2 26 2 26 –
Portugal – – – – – – – 1 32 1 18 –
Qatar – – – – – – – 5 39 2 28 –
Republic of Korea 3 x – – <1 x 1 x 7 x – 1 27 5 23 –
Republic of Moldova 6 11 x 3 x <1 x 2 x 5 x – 3 18 2 27 58 x
Romania 13 x – – 1 x 4 x 8 x – 3 25 2 27 –
Russian Federation – – – – – – – 2 21 2 23 –
Rwanda 37 w 49 21 <1 w 2 w 6 98 f 6 11 8 22 90
Saint Kitts and Nevis – – – – – – – 4 28 3 – –
Saint Lucia 2 5 x – x,p 1 x 4 x 6 x – 4 23 4 22 75 x
Saint Vincent and the Grenadines – – – – – – – 3 29 4 25 –
Samoa 5 6 3 1 4 5 – <1 53 1 31 96
San Marino – – – – – – – <1 <1 <1 – –
Sao Tome and Principe 17 25 7 1 4 2 23 f 5 13 8 46 91
Saudi Arabia 9 x – – 5 x 12 x 6 x – 8 36 3 43 70 x,y
Senegal 17 27 6 1 9 1 58 f 9 10 11 50 62
Serbia 6 14 4 1 4 14 – 2 27 2 27 –
Seychelles 8 – – 1 x 4 x 10 x – 6 23 5 22 –
Sierra Leone 38 42 29 4 9 9 98 f 7 11 10 48 85
Singapore 4 x – – 1 x 4 x 3 x – 2 22 8 22 –
Slovakia – – – – – – – 1 23 2 27 –
Slovenia – – – – – – – 1 27 2 24 –
Solomon Islands 32 37 25 4 8 5 – 1 23 2 39 88
Somalia 25 x 52 x 25 x 5 x 15 x 3 x 11 f 7 13 10 44 7 x
South Africa 27 36 13 1 2 13 47 f 5 25 3 26 91
South Sudan 31 x 31 x 27 x 12 x 24 x 6 x 51 f <1 <1 <1 34 60 x
Spain – – – – – – – 1 34 1 17 –
Sri Lanka 17 25 12 3 15 2 93 f 15 13 13 33 95 y
State of Palestine 7 7 6 <1 1 8 – – – – – 88
Sudan 38 44 21 5 17 3 20 f <1 <1 <1 31 34
Suriname 9 x 13 x 6 x 2 x 6 x 4 x – 4 31 3 24 –
Sweden – – – – – – – 1 24 2 15 –
Switzerland – – – – – – – <1 22 3 18 –
Syrian Arab Republic 28 x 33 x 22 x 5 x 12 x 18 x 91 f 6 28 3 34 65 x
Tajikistan 18 22 17 2 6 3 – 4 15 5 31 91
Thailand 11 13 12 1 5 8 – 8 22 8 32 85
Timor-Leste 51 59 39 2 11 1 66 f 11 13 19 41 83
Togo 28 33 11 1 7 2 87 f 6 10 9 49 77
Tokelau – – – – – – – – – – – –
Tonga 8 7 x 10 x 2 x 5 x 17 x – <1 58 <1 21 –
Trinidad and Tobago 9 x 9 x 15 x 2 x 6 x 11 x – 6 25 3 24 63 x
Tunisia 10 16 x 8 x 2 x 3 x 14 x – 7 25 3 31 –
Turkey 10 19 5 <1 2 11 – 5 30 2 31 85 x
 S TAT I S T I C A L TA B L E S » 2 2 3

TABLE 8. NUTRITION: PRESCHOOL/SCHOOL AGE CHILDREN, WOMEN AND HOUSEHOLDS

Malnutrition among
Malnutrition among preschool-aged children school-aged children Malnutrition among
(0–4 years of age) (5–19 years of age) women
2013–2018* 2016 2016
Vitamin A
Stunted (%) Overweight supplemen- Overweight Underweight Anaemia 15–49 Percentage of
(moderate and severe) Wasted (%) (%) tation, full Thinness (%) (%) 18+ years (%) years (%) households
Countries moderate and moderate
coverage
(%) thin and overweight BMI mild, moderate
consuming
iodized salt
and areas all children poorest 20% richest 20% severe severe and severe 2017 severely thin and obese <18.5 kg/m2 and severe 2013–2018*

Turkmenistan 11 16 11 1 4 6 – f 3 18 4 33 >99
Turks and Caicos Islands – – – – – – – – – – – –
Tuvalu 10 x 8 x 13 x 1 x 3 x 6 x – <1 58 1 – –
Uganda 29 32 17 1 3 4 27 f 6 10 10 29 91
Ukraine 23 x – – 4 x 8 x 27 x – 2 21 2 24 36 x
United Arab Emirates – – – – – – – 5 36 3 28 –
United Kingdom – – – – – – – 1 31 2 15 –
United Republic of Tanzania 34 40 19 1 5 4 87 f 7 12 10 37 76
United States 4 – – <1 x <1 9 – 1 42 2 13 –
Uruguay 11 x – – <1 x 1 x 7 x – 2 33 1 21 –
Uzbekistan 20 x 21 x 16 x 2 x 4 x 12 x 99 f 3 17 4 36 82 x
Vanuatu 29 39 16 1 4 5 – 2 31 3 24 63
Venezuela (Bolivarian Republic of) 13 x – – – 4 x 6 x – 2 34 2 24 –
Viet Nam 25 41 x,r 6 x,r 1 6 5 99 f,w 14 10 18 24 61 x
Yemen 46 59 26 5 16 2 – f 14 20 9 70 49
Zambia 40 47 28 2 6 6 99 f 6 13 9 34 88
Zimbabwe 27 33 17 1 3 6 43 f 6 15 6 29 93

SUMMARY
East Asia and Pacific 8 44 q 22 q 1 3 6 74 6 23 8 27 92
Europe and Central Asia – – – – – – 2 26 2 23 –
Eastern Europe and Central
9 e 18 q 8 q 1 e 2 e 15 e – 3 23 2 28 –
Asia
Western Europe – – – – – – 1 30 2 18 –
Latin America and Caribbean 9 24 q 7 q <1 1 7 – 2 30 3 22 –
Middle East and North Africa 15 – – 3 8 11 – 6 31 3 34 –
North America 3 d – – <1 d <1 d 9 d – 1 41 2 13 –
South Asia 34 51 22 5 15 3 66 25 8 23 50 89
Sub-Saharan Africa 33 46 20 2 8 4 55 7 10 10 39 80
Eastern and Southern Africa 34 42 22 2 6 4 57 7 11 9 31 82
West and Central Africa 34 50 18 2 6 4 53 9 10 10 48 76
Least developed countries 32 45 22 2 8 4 58 10 10 14 40 74
World 22 45 20 2 7 6 62 11 18 9 33 88
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES NOTES

Stunting (preschoolers) –
Moderate and severe: Percentage of
children aged 0–59 months who are
below minus two standard
deviations from median
height-for-age of the WHO Child
Growth Standards.
Wasting (preschoolers) –
Moderate and severe: Percentage of
children aged 0–59 months who are
below minus two standard
deviations from median
weight-for-height of the WHO Child
Growth Standards.
Wasting (preschoolers) – Severe:
Percentage of children aged 0–59
months who are below minus three
standard deviations from median
weight-for-height of the WHO Child
Growth Standards.
Overweight (preschoolers) –
Moderate and severe: Percentage of
children aged 0–59 months who are
above two standard deviations from
median weight-for-height of the
WHO Child Growth Standards
(includes severe overweight).
Vitamin A supplementation, full
coverage – The estimated
percentage of children aged 6–59
months reached with 2 doses of
vitamin A supplements
approximately 4–6 months apart in a
given calendar year.
Thinness (school-age children)
– Percentage of children aged 5–19
years with BMI < −2 SD of the
median according to the WHO
growth reference for school-age
children and adolescents.
Overweight (school-age
children) – Percentage of children
aged 5–19 years with BMI > 1 SD
of the median according to the WHO
growth reference for school-age
children and adolescents.
Underweight (women 18+) –
Percentage of women 18+ years of
age with a body mass index (BMI)
less than 18.5 kg/m2.
Anaemia (women 15–49 years)
– Percentage of women aged 15−49
years with a haemoglobin
concentration less than 120 g/L for
non-pregnant women and lactating
women, and less than 110 g/L for
pregnant women, adjusted for
altitude and smoking.
Households consuming salt with
iodine – Percentage of households
consuming salt with any iodine (>0
ppm).
Stunting, overweight, wasting
and severe wasting (preschool
children) – DHS, MICS, and other
national household surveys. Last
update: March 2019.
Vitamin A supplementation –
UNICEF. Last Update: February
2019.
Thinness and overweight
(school-age children), and
underweight (women 18+)
– NCD Risk Factor Collaboration
(NCD-RisC), based on Worldwide
trends in body mass index,
underweight, overweight and
obesity from 1975 to 2016: a
pooled analysis of 2416
population-based measurement
studies in 128.9 million children,
adolescents, and adults. The
Lancet 2017, 390 (10113):
2627–2642. Last update: August
2019.
Underweight (women 18+)
– Global Health Observatory, WHO.
Last update: August 2019.
Anaemia (women 15–49 years)
– Global Health Observatory, WHO.
Last update: August 2019.
Iodized salt consumption – DHS,
MICS, other national household
surveys, and school-based surveys.
Last update: June 2019.
– Data not available.
a Full coverage with vitamin A
supplements is reported as the lower
percentage of 2 annual coverage
points (i.e., lower point between
semester 1 (January–June) and
semester 2 (July–December) of 2017.
Data are only presented for VAS priori- e Consecutive low population coverage,
ty countries; thus aggregates are only
based on and representative of these
priority countries.
b Cannot be confirmed whether the
reported value includes households
without salt or not.
c Global and regional averages for
stunting (moderate and severe), over-
weight (moderate and severe),wasting
(moderate and severe) and wasting
(severe) are estimated using statistical
modelling data from the UNICEF-
WHO-World Bank Group Joint Child
Malnutrition Estimates, March 2019
Edition. For more information see
<data.unicef.org/malnutrition>. Dis-
aggregations for stunting (moderate
and severe) are population-weighted,
which means using the most recent
estimate for each country with data
between 2013 and 2018; therefore
disaggregations may not coincide
with total estimates at the global and
regional level presented in this table.
d For stunting, wasting and severe
wasting estimates, the Northern
America regional average is based
only on United States data; the
Australia and New Zealand regional
estimates for stunting and overweight
are based only on Australian data.
interpret with caution.
f Identifies countries which are desig-
nated ‘priority’. Priority countries for
national vitamin A supplementation
programmes are identified as those
having high under-five mortality rates
(over 70 per 1,000 live births), and/
or evidence of vitamin A deficiency
among this age group, and/or a
history of vitamin A supplementation
programmes.
p Based on small denominators (typical-
ly 25-49 unweighted cases). No data
based on fewer than 25 unweighted
cases are displayed.
q Regional estimates for East Asia and
Pacific exclude China, Latin America
and the Caribbean exclude Brazil,
Eastern Europe and Central Asia
exclude the Russian Federation.
r Disaggregated data are from different
sources than the data presented for all
children for the same indicator.
w Reduced age range. For vitamin A sup-
plementation, this identifies countries
with national vitamin A supplementa-
tion programmes targeted towards a
reduced age range. Coverage figure is
reported as targeted.
x Data refer to years or periods other
than those specified in the column
heading. Such data are not included in
the calculation of regional and global
averages. Estimates from data years
prior to 2000 are not displayed.
y Data differ from the standard defini-
tion or refer to only part of a country.
If they fall within the noted reference
period, such data are included in the
calculation of regional and global
averages.
z Identifies countries for which the
national estimate is not displayed but
for which the national estimate has
been used for regional and all priority
country estimates.
* Data refer to the most recent year
available during the period specified in
the column heading.
 224 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 9. EARLY CHILDHOOD DEVELOPMENT

Early Learning materials at home
Attendance in early childhood Early stimulation and responsive care stimulation 2010–2018*
education by adults+ and Children with inadequate supervision
2010–2018* 2010–2018* responsive Children’s books Playthings+ 2010–2018*
Countries poorest richest poorest richest
care by
father+ poorest richest poorest richest poorest richest
and areas total male female 20% 20% total male female 20% 20% 2010–2018* total 20% 20% total 20% 20% total male female 20% 20%
Afghanistan 1 1 1 0 4 73 74 73 72 80 62 y 2 1 5 53 52 57 40 42 39 43 27
Albania 73 73 73 62 88 78 75 80 57 88 14 32 x 16 x 52 x 53 x 57 x 48 x 7 7 6 9 3
Algeria 17 17 16 7 31 78 79 78 64 92 79 y 11 3 23 35 32 36 6 6 5 6 6
Andorra − − − − − − − − − − − − − − − − − − − − − −
Angola − − − − − − − − − − − − − − − − − − − − − −
Anguilla − − − − − − − − − − − − − − − − − − − − − −
Antigua and Barbuda − − − − − − − − − − − − − − − − − − − − − −
Argentina 63 61 66 46 85 84 83 85 73 95 57 y 61 40 83 61 58 63 8 9 8 10 5
Armenia − − − − − − − − − − − − − − − − − − − − − −
Australia − − − − − − − − − − − − − − − − − − − − − −
Austria − − − − − − − − − − − − − − − − − − − − − −
Azerbaijan − − − − − − − − − − − − − − − − − − − − − −
Bahamas − − − − − − − − − − − − − − − − − − − − − −
Bahrain − − − − − − − − − − − − − − − − − − − − − −
Bangladesh 13 13 14 12 18 78 78 78 64 94 10 9 2 23 60 57 60 12 11 12 14 12
Barbados 90 88 91 90 p 97 p 97 97 97 100 p 100 p 46 y 85 83 89 76 68 77 1 2 1 0 3
Belarus 88 86 89 75 91 96 94 97 90 99 68 y 92 83 96 79 77 79 4 4 4 4 5
Belgium − − − − − − − − − − − − − − − − − − − − − −
Belize 55 52 58 29 72 88 89 86 80 94 24 44 23 73 68 70 66 13 15 11 15 11
Benin 19 y 18 y 20 y 5 y 49 y 39 y 39 y 39 y 32 y 56 y 4 y 2 y 0 y 7 y 55 y 39 y 70 y 29 y 28 y 30 y 36 y 22 y
Bhutan 10 10 10 3 27 54 52 57 40 73 51 y 6 1 24 52 36 60 14 13 15 17 7
Bolivia (Plurinational
− − − − − − − − − − − − − − − − − − − − − −
State of)
Bosnia and
13 12 14 2 31 95 95 96 87 100 76 y 56 39 73 56 58 60 2 2 2 3 1
Herzegovina
Botswana 18 x − − − − − − − − − − − − − − − − − − − − −
Brazil 70 y − − − − − − − − − − − − − − − − − − − − −
British Virgin Islands − − − − − − − − − − − − − − − − − − − − − −
Brunei Darussalam − − − − − − − − − − − − − − − − − − − − − −
Bulgaria − − − − − − − − − − − − − − − − − − − − − −
Burkina Faso 3 y 3 y 3 y 14 x 14 x 14 x 12 x 26 x 24 x,y − − − − − − − − − − −
Burundi 7 y 7 y 7 y 1 y 31 y 58 y 58 y 59 y 56 y 67 y 3 y 0 y 0 y 0 y 35 y 29 y 52 y 42 y 42 y 42 y 43 y 30 y
Cabo Verde − − − − − − − − − − − − − − − − − − − − − −
Cambodia 15 y 12 y 17 y 7 y 38 y 59 y 57 y 62 y 48 y 73 y 8 y 4 y 1 y 12 y 34 y 20 y 53 y 10 y 10 y 10 y 16 y 4 y
Cameroon 28 27 29 2 66 44 45 44 50 52 4 4 0 17 53 47 65 34 34 35 52 23
Canada − − − − − − − − − − − − − − − − − − − − − −
Central African
5 5 6 2 17 74 74 74 70 78 42 y 1 0 3 49 41 51 61 60 62 58 60
Republic
Chad 3 y 3 y 3 y 1 y 11 y 47 y 47 y 46 y 41 y 51 y 1 y 1 y 1 y 2 y 41 y 33 y 52 y 47 y 50 y 45 y 43 y 46 y
Chile − − − − − − − − − − − − − − − − − − − − − −
China − − − − − − − − − − − − − − − − − − − − − −
Colombia 37 y − − − − − − − − − − − − − − − − − − − − −
Comoros − − − − − − − − − − − − − − − − − − − − − −
Congo 36 36 37 7 77 59 59 58 47 77 6 3 0 10 51 42 51 42 42 41 54 30
Cook Islands − − − − − − − − − − − − − − − − − − − − − −
Costa Rica 18 17 18 8 40 68 69 66 54 88 52 y 37 13 70 73 68 74 4 4 4 6 3
Côte d'Ivoire 14 14 15 2 51 29 29 29 18 61 5 1 0 7 45 35 53 20 20 19 20 18
Croatia 83 y 74 y 83 y − − − − − − − − − − − − − − − − − − −
Cuba 76 75 77 − − 89 89 90 − − 18 48 − − 78 − − 4 4 4 − −
Cyprus − − − − − − − − − − − − − − − − − − − − − −
Czechia − − − − − − − − − − − − − − − − − − − − − −
Democratic People's
73 73 73 − − 95 y 94 y 95 y 21 y 50 − − 59 − − 16 17 16 − −
Republic of Korea
Democratic Republic
7 y 7 y 7 y 1 y 20 y 52 y 55 y 48 y 45 y 64 y 3 y 1 y 0 y 2 y 27 y 18 y 49 y 49 y 50 y 48 y 57 y 29 y
of the Congo
Denmark − − − − − − − − − − − − − − − − − − − − − −
Djibouti 14 x 12 x 16 x − − 37 y 38 y 35 y − − 28 y 15 x − − 24 x − − 8 8 8 − −
Dominica − − − − − − − − − − − − − − − − − − − − − −
Dominican Republic 40 39 40 16 72 58 58 59 38 73 6 10 2 28 57 57 58 5 5 5 7 3
Ecuador − − − − − − − − − − − − − − − − − − − − − −
Egypt 47 y 48 y 47 y 34 y 50 y − − − − − − − − − − − − 4 4 4 7 2
El Salvador 25 24 26 19 44 59 57 62 45 78 8 18 6 44 62 62 58 4 4 3 4 4
Equatorial Guinea − − − − − − − − − − − − − − − − − − − − − −
Eritrea − − − − − − − − − − − − − − − − − − − − − −
Estonia − − − − − − − − − − − − − − − − − − − − − −
Eswatini 30 26 33 28 48 39 33 44 25 59 2 6 2 19 67 56 78 17 16 17 18 15
Ethiopia − − − − − − − − − − − − − − − − − − − − − −
Fiji − − − − − − − − − − − − − − − − − − − − − −
 S TAT I S T I C A L TA B L E S » 2 2 5

TABLE 9. EARLY CHILDHOOD DEVELOPMENT

Early Learning materials at home

Attendance in early childhood Early stimulation and responsive care stimulation 2010–2018*
education by adults+ and Children with inadequate supervision
2010–2018* 2010–2018* responsive Children’s books Playthings+ 2010–2018*
Countries poorest richest poorest richest
care by
father+ poorest richest poorest richest poorest richest
and areas total male female 20% 20% total male female 20% 20% 2010–2018* total 20% 20% total 20% 20% total male female 20% 20%
Finland − − − − − − − − − − − − − − − − − − − − − −
France − − − − − − − − − − − − − − − − − − − − − −
Gabon − − − − − − − − − − − − − − − − − − − − − −
Gambia 18 17 19 12 32 48 49 47 50 55 21 y 1 0 4 42 28 50 21 22 19 25 18
Georgia 62 y − − − − 83 82 84 85 82 35 y 58 y 40 y 74 y 38 x 41 x 41 x 6 y 6 y 7 y 6 y 8 y
Germany − − − − − − − − − − − − − − − − − − − − − −
Ghana 68 65 72 42 97 40 38 42 23 78 30 y 6 1 23 41 31 51 21 21 21 27 15
Greece − − − − − − − − − − − − − − − − − − − − − −
Grenada − − − − − − − − − − − − − − − − − − − − − −
Guatemala − − − − − − − − − − − − − − − − − − − − − −
Guinea 9 9 9 3 32 31 33 30 22 51 4 0 0 1 32 17 54 34 36 33 38 36
Guinea-Bissau 13 13 14 3 46 34 41 28 33 51 0 1 0 3 31 24 46 31 31 31 27 38
Guyana 61 63 59 45 76 87 85 90 82 94 16 47 25 76 69 65 70 5 5 5 10 1
Haiti 63 y 63 y 63 y 31 y 84 y 54 y 52 y 57 y 34 y 79 y 7 y 8 y 1 y 20 y 48 y 33 y 58 y 22 y 23 y 22 y 28 y 15 y
Holy See − − − − − − − − − − − − − − − − − − − − − −
Honduras 19 17 21 13 28 39 38 39 20 64 17 11 1 34 78 74 81 4 5 4 8 2
Hungary − − − − − − − − − − − − − − − − − − − − − −
Iceland − − − − − − − − − − − − − − − − − − − − − −
India − − − − − − − − − − − − − − − − − − − − − −
Indonesia 17 16 18 − − − − − − − − − − − − − − − − − − −
Iran (Islamic Republic
20 y 19 y 22 y − − 70 y 69 y 70 y − − 60 y 36 y − − 67 y − − 15 y 15 y 15 y − −
of)
Iraq 2 2 3 1 5 44 y 44 y 45 y 31 y 53 y 10 y 3 1 9 47 52 43 10 10 10 12 12
Ireland − − − − − − − − − − − − − − − − − − − − − −
Israel − − − − − − − − − − − − − − − − − − − − − −
Italy − − − − − − − − − − − − − − − − − − − − − −
Jamaica 92 92 91 88 100 88 86 90 76 86 28 y 55 34 73 61 64 56 2 2 2 2 1
Japan − − − − − − − − − − − − − − − − − − − − − −
Jordan 13 y 12 y 14 y 5 y 35 y 92 y 92 y 91 y 85 y 99 y 32 y 16 y 6 y 32 y 71 y 69 y 66 y 16 y 17 y 16 y 16 y 21 y
Kazakhstan 55 53 58 45 70 86 84 87 83 95 7 51 35 73 60 63 61 5 4 6 8 3
Kenya − − − − − − − − − − − − − − − − − − − − − −
Kiribati − − − − − − − − − − − − − − − − − − − − − −
Kuwait − − − − − − − − − − − − − − − − − − − − − −
Kyrgyzstan 23 23 23 12 50 72 74 70 63 73 3 27 15 54 59 63 54 5 5 4 6 5
Lao People's
32 30 34 13 69 30 y 29 y 30 y 21 y 49 y 7 y 4 0 18 61 51 63 12 13 12 17 6
Democratic Republic
Latvia − − − − − − − − − − − − − − − − − − − − − −
Lebanon 62 x 63 x 60 x − − 56 x,y 58 x,y 54 x,y − − 74 x,y 29 x − − 16 x,y − − 9 x 8 x 10 x − −
Lesotho − − − − − − − − − − − − − − − − − − − − − −
Liberia − − − − − − − − − − − − − − − − − − − − − −
Libya − − − − − − − − − − − − − − − − − − − − − −
Liechtenstein − − − − − − − − − − − − − − − − − − − − − −
Lithuania − − − − − − − − − − − − − − − − − − − − − −
Luxembourg − − − − − − − − − − − − − − − − − − − − − −
Madagascar − − − − − − − − − − − − − − − − − − − − − −
Malawi 39 37 41 26 67 29 29 30 22 44 3 1 0 6 45 35 66 37 37 37 39 28
Malaysia 53 52 55 − − 25 25 24 − − − 56 − − 62 − − 3 3 3 − −
Maldives 78 y 78 y 79 y 69 y 82 p,y 96 y 96 y 97 y 97 y − 25 y 59 y 50 y 70 y 48 y 50 y 33 y 12 y 10 y 14 y 11 y 22 y
Mali 5 6 5 1 21 55 55 55 53 65 5 0 0 2 52 42 70 32 32 32 31 27
Malta − − − − − − − − − − − − − − − − − − − − − −
Marshall Islands 5 5 5 4 11 72 72 73 71 83 2 19 3 44 71 61 82 9 9 10 10 9
Mauritania 12 12 12 3 30 44 46 42 30 65 5 1 0 3 33 24 52 34 35 34 39 26
Mauritius − − − − − − − − − − − − − − − − − − − − − −
Mexico 60 58 62 58 71 76 71 80 62 94 14 35 15 64 76 74 85 5 5 5 8 3
Micronesia
− − − − − − − − − − − − − − − − − − − − − −
(Federated States of)
Monaco − − − − − − − − − − − − − − − − − − − − − −
Mongolia 68 68 68 36 90 55 55 55 38 71 10 33 13 57 56 57 58 10 9 11 15 8
Montenegro 40 39 42 7 66 98 97 99 93 98 45 73 48 87 60 61 66 3 3 3 2 3
Montserrat − − − − − − − − − − − − − − − − − − − − − −
Morocco 39 x 36 x 41 x 6 x 78 x 36 y 36 y 36 y 26 y 47 y 65 y 21 x,y 9 x,y 52 x,y 14 x,y 19 x,y 7 x,y 7 − − − −
Mozambique − − − − − 47 x 45 x 48 x 48 x 50 x 20 x,y 3 x 2 x 10 x − − − 33 x 33 x 32 x
Myanmar 23 y 22 y 25 y 11 y 42 y 52 y 51 y 53 y 41 y 73 y 6 y 5 y 1 y 15 y 72 y 64 y 76 y 13 y 14 y 13 y 21 y 5 y
Namibia − − − − − − − − − − − − − − − − − − − − − −
Nauru − − − − − − − − − − − − − − − − − − − − − −
Nepal 51 52 49 41 84 67 70 64 51 90 10 5 1 16 59 60 60 21 20 21 30 12
Netherlands − − − − − − − − − − − − − − − − − − − − − −
 226 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 9. EARLY CHILDHOOD DEVELOPMENT

Early Learning materials at home

Attendance in early childhood Early stimulation and responsive care stimulation 2010–2018*
education by adults+ and Children with inadequate supervision
2010–2018* 2010–2018* responsive Children’s books Playthings+ 2010–2018*
Countries poorest richest poorest richest
care by
father+ poorest richest poorest richest poorest richest
and areas total male female 20% 20% total male female 20% 20% 2010–2018* total 20% 20% total 20% 20% total male female 20% 20%
New Zealand − − − − − − − − − − − − − − − − − − − − − −
Nicaragua − − − − − − − − − − − − − − − − − − − − − −
Niger − − − − − − − − − − − − − − − − − − − − − −
Nigeria 36 36 35 8 78 63 62 63 46 87 11 6 0 19 46 38 60 32 32 31 31 30
Niue − − − − − − − − − − − − − − − − − − − − − −
North Macedonia 35 − − − − 92 92 91 81 96 71 y 52 18 81 71 70 79 5 5 5 11 1
Norway − − − − − − − − − − − − − − − − − − − − − −
Oman 29 28 31 81 78 84 − − 22 25 − − 75 − − 45 44 45 − −
Pakistan − − − − − − − − − − − − − − − − − − − − − −
Palau − − − − − − − − − − − − − − − − − − − − − −
Panama 37 38 35 28 67 74 73 74 55 89 45 y 26 7 59 69 67 68 3 3 2 6 1
Papua New Guinea − − − − − − − − − − − − − − − − − − − − − −
Paraguay 31 30 32 10 61 64 62 65 40 90 17 y 23 3 61 60 55 65 3 2 3 4 2
Peru 77 y 76 y 79 y 70 y 90 y − − − − − − − − − − − − − − − − −
Philippines − − − − − − − − − − − − − − − − − − − − − −
Poland − − − − − − − − − − − − − − − − − − − − − −
Portugal − − − − − − − − − − − − − − − − − − − − − −
Qatar 41 41 41 − − 88 89 88 − − 85 y 40 − − 55 − − 12 12 11 − −
Republic of Korea − − − − − − − − − − − − − − − − − − − − − −
Republic of Moldova 71 74 67 50 88 89 86 92 81 95 47 y 68 33 87 68 75 69 6 6 6 9 5
Romania 82 y 82 y 83 y − − − − − − − − − − − − − − − − − − −
Russian Federation − − − − − − − − − − − − − − − − − − − − − −
Rwanda 13 y 12 y 14 y 3 y 45 y 44 y 43 y 45 y 32 y 63 y 2 y 1 y 0 y 3 y 30 y 21 y 41 y 35 y 35 y 35 y 38 y 21 y
Saint Kitts and Nevis − − − − − − − − − − − − − − − − − − − − − −
Saint Lucia 85 87 84 − − 93 89 96 − − 50 y 68 − − 59 − − 5 5 5 − −
Saint Vincent and
− − − − − − − − − − − − − − − − − − − − − −
the Grenadines
Samoa − − − − − − − − − − − − − − − − − − − − − −
San Marino − − − − − − − − − − − − − − − − − − − − − −
Sao Tome and
36 34 39 21 63 63 63 63 48 74 3 6 1 20 65 65 57 16 17 14 26 8
Principe
Saudi Arabia − − − − − − − − − − − − − − − − − − − − − −
Senegal 24 y 23 y 26 y 5 y 56 y 29 y 28 y 31 y 21 y 44 y 1 y 1 y 0 y 4 y 24 y 13 y 31 y 28 y 28 y 28 y 33 y 14 y
Serbia 50 52 49 9 82 96 95 96 87 98 37 72 44 83 75 78 76 1 2 1 3 2
Seychelles − − − − − − − − − − − − − − − − − − − − − −
Sierra Leone 12 11 12 1 41 19 y 19 y 19 y 13 y 31 y 5 y 2 0 9 41 27 66 30 30 30 32 25
Singapore − − − − − − − − − − − − − − − − − − − − − −
Slovakia − − − − − − − − − − − − − − − − − − − − − −
Slovenia − − − − − − − − − − − − − − − − − − − − − −
Solomon Islands − − − − − − − − − − − − − − − − − − − − − −
Somalia 2 x 2 x 2 x 1 x 6 x 79 x 80 x 79 x 76 x 85 x 48 x,y − − − − − − − − − − −
South Africa 48 y − − − − − − − − − − − − − − − − − − − − −
South Sudan 6 6 6 2 13 − − − − − − − − − − − − − − − − −
Spain − − − − − − − − − − − − − − − − − − − − − −
Sri Lanka − − − − − − − − − − − − − − − − − − − − − −
State of Palestine 26 27 26 21 38 78 77 78 69 87 12 20 13 31 69 64 72 14 14 15 15 12
Sudan 22 22 23 7 59 − − − − − − 2 0 7 46 36 55 − − − − −
Suriname 34 33 35 16 63 73 71 75 56 91 26 y 25 4 61 59 61 60 7 7 7 9 8
Sweden − − − − − − − − − − − − − − − − − − − − − −
Switzerland − − − − − − − − − − − − − − − − − − − − − −
Syrian Arab Republic 8 x 8 x 7 x 4 x 18 x 70 x 70 x 69 x 52 x 84 x 62 x,y 30 x 12 x 53 x 52 x 52 x 51 x 17 x 17 x 17 x 22 x 15 x
Tajikistan 6 − − − − 74 x 73 x 74 x 56 x 86 x 23 x,y 17 x 4 x 33 x 46 x 43 x 44 x 13 x 13 x 12 x 15 x 11 x
Thailand 85 84 85 86 84 93 93 92 87 98 34 41 23 73 76 81 67 2 6 6 8 3
Timor-Leste 14 y 13 y 16 y 9 y 16 y 81 y 83 y 79 y 72 y 89 y 15 y 4 y 2 y 9 y 40 y 22 y 61 y 29 y 29 y 30 y 33 y 26 y
Togo 26 y 26 y 26 y 15 y 52 y 26 y 26 y 26 y 22 y 44 y 3 y 1 y 0 y 3 y 34 y 22 y 48 y 29 y 26 y 33 y 36 y 26 y
Tokelau − − − − − − − − − − − − − − − − − − − − − −
Tonga − − − − − − − − − − − − − − − − − − − − − −
Trinidad and Tobago 85 85 84 72 93 96 95 96 94 100 57 y 76 63 93 76 75 82 2 2 1 3 1
Tunisia 44 42 47 13 81 71 68 74 44 90 71 y 18 3 40 53 46 56 13 13 14 18 9
Turkey − − − − − − − − − − − − − − − − − − − − − −
Turkmenistan 43 43 43 17 81 94 94 95 92 98 15 48 30 66 53 59 56 1 0 1 1 1
Turks and Caicos
− − − − − − − − − − − − − − − − − − − − − −
Islands
Tuvalu − − − − − − − − − − − − − − − − − − − − − −
Uganda 37 y 34 y 39 y 15 y 66 y 53 y 51 y 55 y 38 y 74 y 3 y 2 y 0 y 8 y 50 y 39 y 59 y 37 y 37 y 37 y 49 y 21 y
Ukraine 52 54 50 30 68 98 97 98 95 99 71 y 91 92 92 52 61 51 7 6 7 11 5
United Arab Emirates − − − − − − − − − − − − − − − − − − − − − −
United Kingdom − − − − − − − − − − − − − − − − − − − − − −
 S TAT I S T I C A L TA B L E S » 2 2 7

TABLE 9. EARLY CHILDHOOD DEVELOPMENT

Early Learning materials at home

Attendance in early childhood Early stimulation and responsive care stimulation 2010–2018*
education by adults+ and Children with inadequate supervision
2010–2018* 2010–2018* responsive Children’s books Playthings+ 2010–2018*
Countries poorest richest poorest richest
care by
father+ poorest richest poorest richest poorest richest
and areas total male female 20% 20% total male female 20% 20% 2010–2018* total 20% 20% total 20% 20% total male female 20% 20%
United Republic of
− − − − − − − − − − − − − − − − − − − − − −
Tanzania
United States − − − − − − − − − − − − − − − − − − − − − −
Uruguay 81 83 80 − − 93 94 91 − − 66 y 59 − − 75 − − 3 3 3 − −
Uzbekistan 32 y 33 y 31 y − − 91 x 91 x 90 x 83 x 95 x 54 x,y 43 x 32 x 59 x 67 x 74 x 62 x 5 x 5 x 5 x 6 x 7 x
Vanuatu − − − − − − − − − − − − − − − − − − − − − −
Venezuela (Bolivarian
66 y − − − − − − − − − − − − − − − − − − − − −
Republic of)
Viet Nam 71 74 69 53 86 76 76 76 52 96 15 26 6 58 52 44 54 7 6 8 14 2
Yemen 3 x 3 x 3 x 0 x 8 x 33 x 34 x 32 x 16 x 56 x 37 x,y 10 x 4 x 31 x 49 x 45 x 49 x 34 x 36 x 33 x 46 x 22 x
Zambia − − − − − − − − − − − − − − − − − − − − − −
Zimbabwe 22 20 23 17 34 43 43 43 35 59 3 3 1 12 62 48 74 19 19 18 25 7

SUMMARY
East Asia and Pacific − − − − − − − − − − − − − − − − − − − − − −
Europe and Central
− − − − − − − − − − − − − − − − − − − − − −
Asia
Eastern Europe
− − − − − − − − − − − − − − − − − − − − − −
and Central Asia
Western Europe − − − − − − − − − − − − − − − − − − − − − −
Latin America and
61 − − − − − − − − − − − − − − − − − − − − −
Caribbean
Middle East and
28 28 28 20 37 − − − − − − − − − − − − 9 9 9 9 6
North Africa
North America − − − − − − − − − − − − − − − − − − − − − −
South Asia − − − − − − − − − − − − − − − − − − − − − −
Sub-Saharan Africa 26 24 25 8 55 51 51 51 40 70 7 3 0 10 42 33 57 35 35 34 38 27
Eastern and
− − − − − − − − − − − − − − − − − − − − − −
Southern Africa
West and Central
24 24 24 7 56 52 52 51 41 71 8 3 0 12 41 32 56 35 35 34 38 28
Africa
Least developed
17 16 17 8 35 56 56 55 47 71 10 3 1 9 46 38 57 31 31 31 36 22
countries
World − − − − − − − − − − − − − − − − − − − − − −
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES NOTES

Attendance in early childhood education
– Percentage of children 36–59 months old who
are attending an early childhood education
programme.
Early stimulation and responsive care by
adults – Percentage of children 36–59 months
old with whom an adult has engaged in four or
more of the following activities to promote
learning and school readiness in the past 3 days:
a) reading books to the child, b) telling stories to
the child, c) singing songs to the child, d) taking
the child outside the home, e) playing with the
child, and f) spending time with the child naming,
counting or drawing things.
Early stimulation and responsive care by
father – Percentage of children 36–59 months
old whose father has engaged in four or more of
the following activities to promote learning and
school readiness in the past 3 days: a) reading
books to the child, b) telling stories to the child,
c) singing songs to the child, d) taking the child
outside the home, e) playing with the child, and f)
spending time with the child naming, counting or
drawing things.
Learning materials at home: Children’s
books – Percentage of children 0–59 months old
who have three or more children’s books at
home.
Learning materials at home: Playthings
– Percentage of children 0–59 months old with
two or more of the following playthings at home:
household objects or objects found outside
(sticks, rocks, animals, shells, leaves etc.),
homemade toys or toys that came from a store.
Children with inadequate supervision –
Percentage of children 0–59 months old left
alone or in the care of another child younger than
10 years of age for more than one hour at least
once in the past week.
Attendance in early childhood education
– Demographic and Health Surveys (DHS),
Multiple Indicator Cluster Surveys (MICS), and
other national surveys. Last update: August 2019.
Early stimulation and responsive care by
adults – DHS, MICS and other national surveys.
Last update: August 2019.
Early stimulation and responsive care by
father – DHS, MICS and other national surveys.
Last update: August 2019.
Learning materials at home: Children’s
books – DHS, MICS and other national surveys.
Last update: August 2019.
Learning materials at home: Playthings –
DHS, MICS and other national surveys. Last
update: August 2019.
Children with inadequate supervision –
DHS, MICS and other national surveys. Last
update: August 2019.
– Data not available.
p Based on small denominators (typically 25–49
unweighted cases). No data based on fewer than
25 unweighted cases are displayed.
x Data refer to years or periods other than those
specified in the column heading. Such data are
not included in the calculation of regional and
global averages.
y Data differ from the standard definition or refer to
only part of a country. If they fall within the noted
reference period, such data are included in the
calculation of regional and global averages.
+ A more detailed explanation of the methodology
and the changes in calculating these estimates
can be found in the General Note on the Data,
page 180.
* Data refer to the most recent year available
during the period specified in the column heading.
 228 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 10. EDUCATION

Equitable access Completion Learning
Out-of-school rate Completion rate Learning outcomes
2012–2018* 2012–2018* 2010–2018*
Proportion of
Proportion of children at the Proportion of
children in grade 2 end of primary children at the end
One year Lower Upper Lower Upper or 3 achieving achieving of lower secondary Youth (15–24
before primary Primary secondary secondary Primary secondary secondary minimum minimum achieving minimum years) literacy
Countries entry age education education education education education education proficiency level proficiency level proficiency level rate (%)
and areas male female male female male female male female male female male female male female reading math reading math reading math male female
Afghanistan − − − − − − 46 69 67 40 49 26 32 14 47 52 55 63 − − 62 32
Albania 10 11 2 4 1 4 17 18 91 93 97 96 43 60 86 − 95 97 48 39 99 99
Algeria − − 0 2 − − − − 93 94 57 72 30 47 − 41 x − − 21 19 − −
Andorra − − − − − − − − − − − − − − − − − − − − − −
Angola 30 38 − − − − − − 53 49 41 31 21 15 − − − − − − 85 71
Anguilla − − − − − − − − − − − − − − 59 38 76 67 − − − −
Antigua and Barbuda 14 12 18 17 16 24 21 22 − − − − − − 38 46 50 78 − − − −
Argentina 1 3 0 1 1 1 13 5 95 97 72 81 53 66 62 63 67 59 62 38 99 100
Armenia − − 8 8 8 6 − − 100 99 94 99 91 96 − − − 95 − 76 100 100
Australia 12 13 4 3 1 2 2 0 − − − − − − 95 96 94 95 82 78 − −
Austria 2 0 − − 0 1 7 7 − − − − − − − − 87 95 84 87 − −
Azerbaijan 39 39 7 5 0 0 − − − − − − − − − − 82 71 27 x 55 x 100 100
Bahamas 65 60 15 8 11 5 15 10 − − − − − − − − − − − − − −
Bahrain 23 24 1 1 3 0 7 5 − − − − − − − 72 − − − 75 94 95
Bangladesh − − 8 2 − − 37 38 69 79 53 55 31 26 65 39 91 81 87 57 92 94
Barbados 8 12 10 9 4 0 − − 99 99 98 98 91 97 − − 87 60 − − 100 100
Belarus 1 4 4 4 2 1 2 0 100 100 100 100 96 98 − − − − − − − −
Belgium 0 0 1 1 3 3 1 1 − − − − − − − − − − 80 80 − −
Belize 16 16 0 1 11 11 38 34 78 x 86 x 40 x 48 x 20 x 25 x 25 x − − − − − − −
Benin 12 12 − − 26 43 46 66 51 44 25 13 12 5 10 34 52 40 − − 64 41
Bhutan − − 19 17 20 10 34 27 67 x 71 x 41 x 38 x 25 x 18 x − − − − 33 51 90 84
Bolivia (Plurinational State of) 8 9 7 8 13 13 17 18 − − − − − − − − − − − − 99 99
Bosnia and Herzegovina − − − − − − − − 99 100 97 97 92 92 − − − − − 77 x 100 100
Botswana 67 65 11 10 − − − − − − − − − − 56 61 66 66 79 80 96 99
Brazil 4 1 4 2 3 4 19 16 94 97 73 82 53 64 78 77 97 100 49 30 99 99
British Virgin Islands − − − − − − − − − − − − − − − − − − − − − −
Brunei Darussalam 5 5 3 4 − − 20 16 − − − − − − − − − − − − 99 100
Bulgaria 5 4 7 7 6 7 8 12 − − − − − − − − 93 92 59 58 98 98
Burkina Faso 83 83 22 24 48 46 67 68 32 x 29 x 13 x 6 x 6 x 2 x 35 59 57 59 − − 57 44
Burundi 58 58 4 2 31 27 60 57 46 54 26 19 4 3 79 97 56 87 − − 85 75
Cabo Verde 21 20 13 14 20 20 37 32 − − − − − − − − − − − − 98 99
Cambodia 58 56 9 10 12 14 − − 68 79 41 39 20 20 − − 61 − 38 17 92 93
Cameroon 54 54 1 9 31 39 48 57 67 64 46 41 18 14 30 55 49 35 − − 85 76
Canada − − − − 0 0 8 8 − − − − − − − − − − 89 86 − −
Central African Republic − − 23 40 44 66 79 90 54 x 33 x 16 x 8 x 8 x 6 x − − − − − − 49 27
Chad 89 90 17 34 51 70 71 88 31 24 18 10 15 6 18 48 16 19 39 33 41 22
Chile 3 3 5 5 8 8 7 6 − − − − − − 70 63 94 98 72 63 99 99
China − − − − − − − − 97 97 93 93 64 67 82 85 − − 80 79 100 100
Colombia 13 12 7 6 6 5 17 15 91 95 74 81 69 78 82 82 87 57 89 79 98 99
Comoros 60 62 15 16 30 29 57 55 75 77 47 45 24 32 − − 66 x 70 x − − 74 70
Congo 79 77 16 9 − − − − 78 82 56 45 28 19 38 71 41 29 − − 86 77
Cook Islands 2 0 2 5 8 7 37 30 − − − − − − − − − − − − − −
Costa Rica 10 11 3 3 5 6 14 9 94 x 95 x 55 x 71 x 38 x 56 x 89 84 94 95 60 38 99 99
Côte d'Ivoire 78 78 7 15 36 49 57 69 60 53 36 22 17 15 17 34 48 27 − − 59 47
Croatia 2 7 4 1 3 0 16 12 − − − − − − − − 99 93 80 68 100 100
Cuba 0 0 3 3 0 0 23 15 99 100 98 98 81 86 − − 94 x 95 x − − 100 100
Cyprus 5 6 2 2 2 2 6 5 − − − − − − 87 x 93 − − 64 78 x 100 100
Czechia 8 8 − − − − 2 2 − − − − − − 98 96 − − 78 78 − −
Democratic People's Republic of
− − − − 8 8 11 11 100 100 100 100 100 100 94 83 − − − − − −
Korea
Democratic Republic of the Congo − − − − − − − − 71 66 59 49 30 21 − − 81 85 − − 91 80
Denmark 3 2 1 1 1 1 14 11 − − − − − − 99 96 − − 85 86 − −
Djibouti 91 91 39 46 48 56 66 72 − − − − − − − − − − − − − −
Dominica 29 30 3 1 − − 10 10 − − − − − − 81 50 40 29 − − − −
Dominican Republic 13 12 6 6 7 9 26 23 88 94 76 89 48 66 46 28 65 63 28 9 99 99
Ecuador 4 4 3 1 − − 16 16 − − − − − − 75 78 68 64 72 43 99 99
Egypt 62 62 2 1 8 7 22 25 91 92 79 81 71 69 5 − − − − 47 89 87
El Salvador 19 18 19 18 16 17 34 35 84 89 73 74 34 36 − 23 x 78 x 79 x − 20 x 98 98
Equatorial Guinea 57 55 56 55 − − − − − − − − − − − − − − − − 98 99
Eritrea 82 83 61 64 53 60 66 71 − − − − − − − − − − − − − −
Estonia 10 7 7 6 − − 5 3 − − − − − − − − − − 89 89 100 100
 S TAT I S T I C A L TA B L E S » 2 2 9

TABLE 10. EDUCATION

Equitable access Completion Learning

Out-of-school rate Completion rate Learning outcomes
2012–2018* 2012–2018* 2010–2018*
Proportion of
Proportion of children at the Proportion of
children in grade 2 end of primary children at the end
One year Lower Upper Lower Upper or 3 achieving achieving of lower secondary Youth (15–24
before primary Primary secondary secondary Primary secondary secondary minimum minimum achieving minimum years) literacy
Countries entry age education education education education education education proficiency level proficiency level proficiency level rate (%)
and areas male female male female male female male female male female male female male female reading math reading math reading math male female

Eswatini − − 24 25 13 13 25 30 52 68 38 45 31 33 − − 99 x 91 x − − 92 95
Ethiopia 61 63 11 17 45 49 73 75 51 51 42 36 13 13 − − − − − − − −
Fiji − − 2 2 − − 30 23 − − − − − − − − − − − − − −
Finland 2 1 1 1 1 1 5 4 − − − − − − 99 97 − − 89 86 − −
France 1 0 1 1 2 2 6 5 − − − − − − 95 87 − − 79 77 − −
Gabon − − − − − − − − 57 67 23 26 11 11 − − 95 x 90 x − − 87 89
Gambia − − 25 17 − − − − 56 57 50 46 31 29 23 31 33 22 − − 66 56
Georgia − − 2 2 1 2 8 5 − − − − − − 86 78 − − 48 43 100 100
Germany − − − − − − − − − − − − − − − − 97 96 84 83 − −
Ghana 13 8 17 15 16 13 31 31 64 68 50 50 42 35 71 55 72 61 − 21 88 83
Greece 12 11 7 7 6 8 10 11 − − − − − − 95 x − − − 73 64 99 99
Grenada 14 17 4 3 2 26 17 11 − − − − − − 54 43 66 57 − − 99 100
Guatemala 19 19 12 12 30 36 56 61 83 77 54 46 27 25 50 41 40 45 15 18 95 93
Guinea 57 61 14 29 41 59 59 75 58 49 43 25 29 15 − − − − − − 57 37
Guinea-Bissau − − − − − − − − 33 26 20 14 11 8 − − − − − − 71 50
Guyana 10 6 5 3 7 5 34 25 96 99 80 88 49 64 − − − − − − 96 97
Haiti − − − − − − − − 49 58 32 38 17 16 − − − − − − − −
Holy See − − − − − − − − − − − − − − − − − − − − − −
Honduras 19 18 17 16 37 35 54 48 81 85 42 55 27 33 93 92 84 77 89 61 95 97
Hungary 8 9 3 3 4 4 12 12 − − − − − − − − 95 92 73 88 99 99
Iceland 2 2 0 1 2 1 18 14 − − − − − − 93 x − − − 78 76 − −
India − − 3 2 17 12 47 49 92 91 82 79 46 40 25 28 − − 17 x 15 x 90 82
Indonesia 6 3 5 10 14 10 17 13 91 92 64 59 40 37 66 49 − − 45 31 100 100
Iran (Islamic Republic of) 51 52 − − 2 2 27 23 − − − − − − 76 65 − − − 63 98 98
Iraq − − − − − − − − 78 73 46 47 45 43 − − − − − − 57 49
Ireland 2 2 0 0 − − 2 0 − − − − − − 97 97 − − 90 94 − −
Israel 2 0 3 2 − − 4 0 − − − − − − 93 − − − 73 68 − −
Italy 1 3 1 2 − − 5 5 − − − − − − 98 93 − − 79 89 100 100
Jamaica 7 4 − − 22 17 24 19 99 x 100 x 97 x 97 x 80 x 83 x 87 14 − − 64 77 94 99
Japan − − 2 2 − − 4 2 − − − − − − − − − − − − − −
Jordan − − − − 28 29 53 46 96 97 86 88 49 63 − 50 − − 54 45 99 99
Kazakhstan 37 35 2 0 − − 3 0 100 100 100 100 95 96 − − − 96 59 91 100 100
Kenya − − 19 15 − − − − 77 82 61 69 44 38 60 71 80 77 − − 87 86
Kiribati − − − − − − − − − − − − − − − − − − − − − −
Kuwait 25 23 7 7 9 4 20 16 − − − − − − 58 33 − − − 45 99 100
Kyrgyzstan 6 4 1 2 1 1 30 26 99 99 95 97 82 85 − − 36 35 17 x 13 x − −
Lao People's Democratic Republic 37 36 6 7 21 22 35 41 87 86 57 55 33 31 83 46 − − − − 94 91
Latvia 2 1 4 2 2 1 5 4 − − − − − − 98 x 96 x − − 82 79 100 100
Lebanon 1 7 9 14 21 26 34 34 − − − − − − − − − − 30 71 − −
Lesotho 65 63 19 17 29 21 46 39 60 83 29 46 20 27 − − 79 x 58 x − − 80 94
Liberia 13 18 61 64 24 31 24 34 36 33 29 23 18 9 − − − − − − − −
Libya − − − − − − − − − − − − − − − − − − − − − −
Liechtenstein 1 0 3 2 2 8 − − − − − − − − − − − − 88 86 − −
Lithuania 1 0 0 0 0 0 4 3 − − − − − − − − 92 99 75 75 100 100
Luxembourg 2 1 1 1 6 4 20 16 − − − − − − 99 x − − − 74 74 − −
Madagascar − − − − − − − − − − − − − − − − 79 x 94 x − − 78 75
Malawi − − − − 23 25 59 65 43 52 23 21 15 13 22 51 24 41 − − 72 73
Malaysia 2 1 2 1 13 11 41 32 − − − − − − 86 71 88 47 73 42 97 98
Maldives 1 3 0 0 − − − − − − − − − − − − − − − − 99 99
Mali 48 52 29 37 52 58 68 77 50 41 36 25 23 12 2 3 12 13 − − 61 39
Malta 4 0 3 0 3 2 16 9 − − − − − − 74 87 − − 64 84 98 99
Marshall Islands 34 35 24 19 23 23 40 28 − − − − − − − − − − − − 98 99
Mauritania − − 25 22 45 44 72 73 64 56 42 34 14 15 − − 47 x 38 x − − − −
Mauritius 8 10 5 3 8 5 22 15 − − − − − − − − 78 79 77 42 98 99
Mexico 1 0 2 0 10 7 32 29 97 96 88 87 25 22 78 78 50 40 66 35 99 99
Micronesia (Federated States of) 20 27 17 15 20 16 − − − − − − − − − − − − − − − −
Monaco − − − − − − − − − − − − − − − − − − − − − −
Mongolia 3 5 1 2 − − − − 96 99 88 93 64 78 − 67 x − − − 66 x 98 99
Montenegro 31 32 3 4 4 5 14 14 100 100 99 99 84 87 − − − − 58 48 99 99
Montserrat − − − − − − − − − − − − − − 57 54 70 81 − − − −
 230 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 10. EDUCATION

Equitable access Completion Learning

Out-of-school rate Completion rate Learning outcomes
2012–2018* 2012–2018* 2010–2018*
Proportion of
Proportion of children at the Proportion of
children in grade 2 end of primary children at the end
One year Lower Upper Lower Upper or 3 achieving achieving of lower secondary Youth (15–24
before primary Primary secondary secondary Primary secondary secondary minimum minimum achieving minimum years) literacy
Countries entry age education education education education education education proficiency level proficiency level proficiency level rate (%)
and areas male female male female male female male female male female male female male female reading math reading math reading math male female

Morocco 42 50 3 3 9 14 26 33 − − − − − − 21 41 − − − 41 95 88
Mozambique − − 11 14 40 48 66 74 43 x 37 x 13 x 10 x 8 x 4 x − − 78 x 67 x − − 79 63
Myanmar − − − − 25 23 50 43 78 84 43 46 13 18 − − − − − − 85 84
Namibia 35 31 4 0 − − − − 75 86 48 62 33 39 − − 86 x 52 x − − 93 95
Nauru 33 16 17 14 21 14 55 60 − − − − − − − − − − − − − −
Nepal 12 18 4 7 14 8 33 18 79 76 68 65 52 39 − − − − − − 90 80
Netherlands 2 1 − − 1 0 1 1 − − − − − − 100 99 − − 82 83 − −
New Zealand 4 3 1 1 2 2 4 0 − − − − − − 76 84 − − 83 78 − −
Nicaragua − − − − − − − − − − − − − − 63 45 76 77 − − − −
Niger 78 78 29 38 61 69 83 89 35 24 10 4 4 1 10 28 8 8 − − 49 32
Nigeria − − − − − − − − 81 79 78 72 70 59 75 28 54 18 − − − −
Niue 77 − − − − − − − − − − − − − − − − − − − − −
North Macedonia 56 56 8 8 − − − − 100 x 99 x 98 x 97 x 80 x 69 x 66 x − − − 29 30 99 99
Norway 4 3 0 0 0 1 8 7 − − − − − − 95 98 − − 85 83 − −
Oman 18 15 1 1 10 7 12 12 − − − − − − 47 61 − − − 52 98 99
Pakistan − − 18 29 42 50 57 67 64 55 55 45 43 38 17 15 52 48 73 68 80 66
Palau − 20 − − − − − − − − − − − − − − − − − − 98 99
Panama 28 26 12 13 10 10 35 31 95 96 75 81 57 68 68 54 77 74 35 x 21 x 98 97
Papua New Guinea 26 27 20 25 7 17 39 50 − − − − − − − − − − − − 65 71
Paraguay 29 29 11 11 4 15 32 30 89 95 57 54 0 0 71 72 69 69 68 68 98 99
Peru 3 3 1 0 2 1 − − 95 95 83 83 78 72 94 71 − − 42 28 99 99
Philippines 21 19 5 4 9 5 24 17 89 95 75 88 54 66 − 34 x − − − 39 x 97 99
Poland 1 1 4 4 5 5 8 7 − − − − − − 95 96 − − 86 83 − −
Portugal 0 1 3 4 1 1 0 3 − − − − − − 98 97 − − 83 76 99 99
Qatar 9 5 1 2 13 9 43 16 − − − − − − 60 64 − − 48 64 95 97
Republic of Korea 3 4 4 3 6 5 1 1 − − − − − − − 100 − − 86 85 − −
Republic of Moldova 7 4 10 10 15 15 36 35 99 100 95 98 63 74 − − 91 x 88 54 50 99 100
Romania 12 12 10 10 9 10 23 22 − − − − − − 86 79 − − 61 60 99 99
Russian Federation 3 4 3 2 2 1 10 9 − − − − − − − − 99 98 84 81 100 100
Rwanda 59 58 6 6 − − − − 48 61 25 30 19 16 − − − − − − 84 86
Saint Kitts and Nevis − − − − − − − − − − − − − − − − − − − − − −
Saint Lucia 8 19 − − 10 14 24 17 99 99 85 98 70 90 68 62 62 46 − − − −
Saint Vincent and the Grenadines 12 10 1 2 − − 11 14 − − − − − − − − − − − − − −
Samoa 65 61 4 3 2 2 23 15 − − − − − − − − − − − − 99 99
San Marino 6 5 7 7 − − − − − − − − − − − − − − − − − −
Sao Tome and Principe 47 45 3 3 12 6 20 18 79 86 32 36 12 12 81 100 − − − − 97 96
Saudi Arabia 63 61 1 0 − − 9 8 − − − − − − 65 43 − − − 34 99 99
Senegal 82 80 29 21 52 45 64 62 48 51 28 24 14 10 18 62 61 59 42 16 76 64
Serbia 3 3 2 1 1 2 12 10 99 100 99 99 71 81 − − − 91 67 61 100 100
Seychelles 3 7 − − − − 5 4 − − − − − − − − 88 74 86 79 99 99
Sierra Leone 65 63 1 1 40 40 61 63 63 65 47 42 27 18 − − − − − − 65 51
Singapore − − − − − − − − − − − − − − 97 99 − − 89 99 100 100
Slovakia 19 17 − − 4 5 10 10 − − − − − − − − 96 88 68 72 − −
Slovenia 4 6 3 2 1 2 5 4 − − − − − − 95 95 − − 85 84 100 100
Solomon Islands 35 34 31 30 − − − − − − − − − − − − − − − − − −
Somalia − − − − − − − − − − − − − − − − − − − − − −
South Africa − − 9 8 − − 15 19 95 98 85 91 45 52 84 39 92 71 84 34 99 99
South Sudan 80 83 64 72 54 67 61 75 30 x 18 x 23 x 10 x 13 x 4 x − − − − − − − −
Spain 4 4 2 1 1 0 2 1 − − − − − − 94 93 − − 84 78 100 100
Sri Lanka − − 2 4 1 2 21 16 − − − − − − 86 84 − − 90 68 99 99
State of Palestine 38 38 6 6 12 7 44 26 99 100 80 93 52 73 − − − − − 52 99 99
Sudan − − 37 38 − − − − 71 73 45 43 34 29 − − − − − − − −
Suriname 10 7 12 8 17 9 42 33 80 90 41 58 19 28 − − − − − − 98 97
Sweden 2 1 0 1 5 4 1 3 − − − − − − 98 95 − 88 82 82 − −
Switzerland 1 1 0 0 − − 17 19 − − − − − − − − − − 80 84 − −
Syrian Arab Republic 61 62 32 33 42 44 68 67 − − − − − − − − − − − 43 − −
Tajikistan 87 88 1 2 − − − − 99 98 95 93 80 63 − − − − − − 100 100
Thailand 3 3 − − 11 11 21 21 98 98 76 88 50 62 − 77 − − 50 46 98 98
Timor-Leste 67 67 21 18 14 12 30 26 77 85 63 70 49 55 80 − − − − − 80 79
Togo − − 5 11 16 28 47 66 66 59 31 20 20 10 20 41 38 48 − − 90 78
 S TAT I S T I C A L TA B L E S » 2 3 1

TABLE 10. EDUCATION

Equitable access Completion Learning

Out-of-school rate Completion rate Learning outcomes
2012–2018* 2012–2018* 2010–2018*
Proportion of
Proportion of children at the Proportion of
children in grade 2 end of primary children at the end
One year Lower Upper Lower Upper or 3 achieving achieving of lower secondary Youth (15–24
before primary Primary secondary secondary Primary secondary secondary minimum minimum achieving minimum years) literacy
Countries entry age education education education education education education proficiency level proficiency level proficiency level rate (%)
and areas male female male female male female male female male female male female male female reading math reading math reading math male female

Tokelau 22 − − − − − 62 80 − − − − − − − − − − − − − −
Tonga − − 5 3 13 9 48 38 − − − − − − 15 x − − − − − 99 100
Trinidad and Tobago − − − − − − − − − − − − − − 78 − 76 63 58 48 100 100
Tunisia − − − − − − − − 94 97 68 80 40 57 − 34 − − 28 25 97 96
Turkey 33 36 5 6 9 10 15 16 99 98 94 90 58 48 − − 72 x 81 60 70 100 99
Turkmenistan − − − − − − − − 100 100 93 91 83 80 − − − − − − 100 100
Turks and Caicos Islands − − − − − − − − − − − − − − − − 70 − − − − −
Tuvalu 6 − − − − − 58 46 − − − − − − − − − − − − − −
Uganda − − 10 8 − − − − 33 36 24 21 16 14 60 72 52 53 − − 86 82
Ukraine − − 8 6 3 3 6 4 100 99 100 100 97 97 − − − 79 x − 81 100 100
United Arab Emirates 12 11 2 4 1 2 13 19 − − − − − − 64 70 − − 60 74 − −
United Kingdom 0 0 0 0 1 1 3 2 − − − − − − − − − − 82 78 − −
United Republic of Tanzania 49 47 20 18 − − 85 88 75 84 31 27 32 27 56 35 97 x 87 x − − 87 85
United States 10 8 4 4 3 1 7 6 − − − − − − 69 95 − − 81 71 − −
Uruguay 3 2 2 2 2 1 23 16 92 95 52 70 45 28 81 75 90 94 61 48 99 99
Uzbekistan 63 64 1 2 4 5 16 17 − − − − − − − − − − − − 100 100
Vanuatu − − 14 12 1 1 43 46 − − − − − − − − − − − − 95 96
Venezuela (Bolivarian Republic of) 17 18 14 14 18 17 32 24 − − − − − − − − − − 58 x 40 x 98 99
Viet Nam 0 1 − − − − − − 96 97 81 87 50 61 − − 99 87 86 81 − −
Yemen 95 96 12 22 23 35 46 68 70 55 55 39 37 23 − 9 − − − − − −
Zambia − − 16 12 − − − − 73 75 54 48 34 23 1 9 56 x 33 x − − 91 87
Zimbabwe 64 63 16 14 8 11 52 55 87 89 66 74 15 11 − − 81 x 73 x − − 88 93

SUMMARY
East Asia and Pacific 14 12 4 4 9 8 23 15 96 96 82 83 56 59 79 77 – – 72 68 99 99
Europe and Central Asia 13 14 3 3 3 4 10 10 – – – – – – – – – – 76 78 100 100
Eastern Europe and Central
22 23 4 4 4 5 14 14 – – – – 67 61 – – – 89 70 75 100 100
Asia
Western Europe 3 3 2 2 2 2 7 6 – – – – – – 96 93 – – 81 81 – –
Latin America and Caribbean 6 4 5 4 7 7 24 21 94 95 75 80 45 50 76 72 75 70 58 38 99 99
Middle East and North Africa 51 53 5 7 12 15 31 36 87 85 66 68 52 53 37 – – – – 46 89 86
North America 7 6 4 4 1 1 5 5 – – – – – – 69 95 – – 82 72 – –
South Asia - - 6 7 18 17 47 49 88 88 75 71 44 38 29 28 – – – – 88 80
Sub-Saharan Africa 57 57 19 24 34 37 54 61 64 64 48 42 35 29 52 42 57 45 – – 80 72
Eastern and Southern Africa 56 57 19 20 32 37 54 60 60 63 41 38 28 25 – – – – – – 86 83
West and Central Africa 56 57 19 27 37 40 53 61 69 65 54 46 41 33 50 35 53 37 – – 73 60
Least developed countries 56 57 17 20 29 34 53 59 60 60 41 36 26 20 – – – – – – 81 73
World 31 31 8 10 15 16 36 36 83 83 71 69 47 43 54 53 – – – 61 92 88

For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES

Out-of-school rate for children one year before the
official primary entry age – Number of children of one year
before primary entry age who are not enrolled in pre-primary or
primary schools, expressed as a percentage of the population
of one year before the official primary entry age.
Out-of-school rate for children of primary school age –
Number of children of official primary school age who are not
enrolled in primary or secondary school, expressed as a
percentage of the population of official primary school age.
Out-of-school rate for children of lower secondary
school age – Number of children of lower secondary school
age who are not enrolled in primary or secondary school,
expressed as a percentage of the population of official lower
secondary school age.
Out-of-school rate for children of upper secondary
school age – Number of children of upper secondary school
age who are not enrolled in primary or secondary school or
higher education, expressed as a percentage of the population
of official upper secondary school age.
Completion rate for primary education – Number of
children or young people aged 3 -5 years above the intended
age for the last grade of primary education who have
completed the last grade of primary school.
Completion rate for lower secondary education – Out of school rate – UNESCO Institute
Number of children or young people aged 3 -5 years above the for Statistics (UIS). Last update: February
intended age for the last grade of lower secondary education 2019.
who have completed the last grade of lower secondary. Completion rate – Demographic and
Completion rate for upper secondary education – Number Health Surveys (DHS), Multiple Indicator
of children or young people aged 3 -5 years above the intended Cluster Surveys (MICS), other national
age for the last grade of upper secondary education who have household surveys, data from routine
completed the last grade of upper secondary. reporting systems. Last update: June
Proportion of children and young people (a) in grade 2/3; 2019.
(b) at the end of primary education; and (c) at the end of Proportion of children and young
lower secondary education achieving at least a people (a) in grade 2/3; (b) at the end
minimum proficiency in (i) reading and (ii) mathematics of primary education; and (c) at the
– Percentage of children and young people in Grade 2 or 3 of
primary education, at the end of primary education and the end
of lower secondary education achieving at least a minimum NOTES
proficiency level in (a) reading and (b) mathematics. – Data not available.
Youth literacy rate – Number of literate persons aged 15–24 x Data refer to years or periods
years, expressed as a percentage of the total population in that other than those specified in the
group. column heading. Such data are
not included in the calculation of
regional and global averages.
* Data refer to the most recent
year available during the period
specified in the column heading.
end of lower secondary education
achieving at least a minimum
proficiency in (i) reading and (ii)
mathematics – United Nations Statistics
Division database. Last update: April
2019.
Youth literacy – UNESCO Institute for
Statistics (UIS). Last update: February
2019.
All data refer to official Interna-
tional Standard Classifications of
Education (ISCED) for the prima-
ry and lower secondary education
levels and thus may not directly
correspond to a country-specific
school system.
 232 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 11. CHILD PROTECTION

Female genital mutilation (%)+ Justification of
Child marriage (%)+ 2010–2018* wife-beating
2012–2018* prevalence attitudes among Sexual violence
Child labour (%)+ Birth registration (%)+ want the adolescents (%)+ Violent discipline (%)+ in childhood (%)
2010–2018* female male 2010–2018* practice to stopc 2012–2018* 2012–2018* 2012–2018*
Countries married married married
and areas total male female by 15 by 18 by 18 total male female womena girlsb male female male female total male female male female

Afghanistan 21 23 20 9 35 7 42 43 42 − − − − 71 y 78 y 74 x,y 75 x,y 74 x,y − 1 y

Albania 3 y 4 y 3 y 1 12 1 98 99 98 − − − − 11 5 48 y 49 y 45 y − −
Algeria 4 y 5 y 4 y 0 3 − 100 100 100 − − − − − 55 y 86 y 88 y 85 y − −
Andorra − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Angola 19 17 20 8 30 6 25 25 25 − − − − 24 25 − − − − 5
Anguilla − − − − − − − − − − − − − − − − − − − −
Antigua and Barbuda − − − − − − − − − − − − − − − − − − − −
Argentina − − − − − − 100 y 100 y 100 y − − − − − 2 72 y 74 y 71 y − −
Armenia 4 5 3 0 5 0 99 100 99 − − − − 25 9 69 71 67 − −
Australia − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Austria − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Azerbaijan − − − 2 x 11 x 0 x 94 x 93 x 94 x − − − − − 24 x 77 x,y 80 x,y 74 x,y − 0 x
Bahamas − − − − − − − − − − − − − − − − − − − −
Bahrain − − − − − − − − − − − − − − − − − − − −
Bangladesh − − − 22 59 4 x 20 20 20 − − − − − 29 y 82 83 82 − 3 y
Barbados 1 y 2 y 1 y 1 11 − 99 99 99 − − − − − 5 75 y 78 y 72 y − −
Belarus 1 y 1 y 1 y 0 3 1 100 y 100 y 100 y − − − − 3 3 65 y 67 y 62 y − −
Belgium − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Belize 3 4 3 6 34 22 96 95 96 − − − − 8 6 65 67 63 − −
Benin 41 42 41 7 26 5 85 85 84 9 0 89 86 17 29 91 92 90 − −
Bhutan 4 y 3 y 4 y 6 x 26 x − 100 100 100 − − − − − 70 x − − − − −
Bolivia (Plurinational State of) − − − 3 20 5 92 y − − − − − − − 17 x − − − − −
Bosnia and Herzegovina − − − 0 4 0 100 x 100 x 99 x − − − − 5 1 55 y 60 y 50 y − −
Botswana − − − − − − 88 y 87 y 88 y − − − − − − − − − − −
Brazil − − − 6 x 26 x − 96 − − − − − − − − − − − − −
British Virgin Islands − − − − − − − − − − − − − − − − − − − −
Brunei Darussalam − − − − − − − − − − − − − − − − − − − −
Bulgaria − − − − − − 100 y 100 y 100 y − − − − − − − − − − −
Burkina Faso 42 y 44 y 40 y 10 x 52 x 4 x 77 77 77 76 13 87 90 40 x 39 x 83 x,y 84 x,y 82 x,y − −
Burundi 31 30 32 3 19 1 84 84 83 − − − − 48 63 90 91 89 0 4
Cabo Verde − − − 3 x 18 x 3 x 91 − − − − − − 24 x 23 x − − − − −
Cambodia 13 12 14 2 19 4 73 74 73 − − − − 26 y 46 y − − − − 2
Cameroon 39 40 38 10 31 4 66 67 65 1 x 1 x,y 85 x 84 x 45 37 85 85 85 4 x 16 x
Canada − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Central African Republic 30 y 29 y 32 y 29 x 68 x 28 x 61 61 62 24 1 − 75 83 x 79 x 92 x,y 92 x,y 92 x,y − −
Chad 39 37 41 30 67 8 12 12 12 38 10 49 x 45 54 69 71 72 71 − 2
Chile 6 7 5 − − − 99 y − − − − − − − − − − − − −
China − − − − − − − − − − − − − − − − − − − −
Colombia 4 4 3 5 23 7 97 97 97 − − − − − − − − − 0 2
Comoros 28 y 25 y 32 y 10 32 12 87 87 87 − − − − 29 43 − − − − 3
Congo 14 13 15 7 27 6 96 96 96 − − − − 45 56 83 83 82 − −
Cook Islands − − − − − − 100 y 100 y 100 y − − − − − − − − − − −
Costa Rica 2 2 2 7 x 21 x − 100 y − − − − − − − 3 x 46 x,y 52 x,y 39 x,y − −
Côte d'Ivoire 29 y 27 y 31 y 7 27 4 72 73 71 37 10 82 79 29 43 87 88 85 − −
Croatia − − − − − − 100 y 100 y 100 y − − − − − − − − − − −
Cuba − − − 5 26 11 100 100 100 − − − − 5 y 4 y 36 37 35 − −
Cyprus − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Czechia − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Democratic People's Republic of
4 5 4 − − − 100 x 100 x 100 x − − − − 4 4 59 63 55 − −
Korea
Democratic Republic of the Congo 27 22 31 10 37 6 25 24 25 − − − − 69 75 82 82 81 − 13
Denmark − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Djibouti − − − 2 x 5 x − 92 x 93 x 91 x 93 x 43 − 51 x − − 72 x,y 73 x,y 71 x,y − −
Dominica − − − − − − − − − − − − − − − − − − − −
Dominican Republic 7 8 6 12 36 8 88 88 88 − − − − − 3 63 64 61 − 1
Ecuador − − − 3 20 − 82 y − − − − − − − − − − − − −
Egypt 5 6 4 2 17 0 x 99 100 99 87 14 y 28 38 − 46 y 93 93 93 − −
El Salvador 10 9 11 6 26 − 99 99 98 − − − − − 10 52 55 50 − −
Equatorial Guinea − − − 9 x 30 x 4 x 54 53 54 − − − − 56 x 57 x − − − − −
Eritrea − − − 13 x 41 x 2 x − − − 83 33 85 82 60 x 51 x − − − − −
Estonia − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Eswatini 8 y 8 y 7 y 1 5 1 54 51 56 − − − − 29 32 88 89 88 − −
Ethiopia 49 y 51 y 46 y 14 40 5 3 3 3 65 16 87 79 33 60 − − − − 5
Fiji − − − − − − − − − − − − − − − 72 x,y − − − −
 S TAT I S T I C A L TA B L E S » 2 3 3

TABLE 11. CHILD PROTECTION

Female genital mutilation (%)+ Justification of

Child marriage (%)+ 2010–2018* wife-beating
2012–2018* prevalence attitudes among Sexual violence
Child labour (%)+ Birth registration (%)+ want the adolescents (%)+ Violent discipline (%)+ in childhood (%)
2010–2018* female male 2010–2018* practice to stopc 2012–2018* 2012–2018* 2012–2018*
Countries married married married
and areas total male female by 15 by 18 by 18 total male female womena girlsb male female male female total male female male female

Finland − − − − − − 100 v 100 v 100 v − − − − − − − − − − −

France − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Gabon 20 y 19 y 17 y 6 22 5 90 91 88 − − − − 47 58 − − − − 9
Gambia − − − 9 30 1 72 73 71 75 56 − 33 42 58 90 x,y 90 x,y 91 x,y − 0
Georgia 2 2 1 1 x 14 x − 100 100 100 − − − − − 5 x 67 x,y 70 x,y 63 x,y − −
Germany − − − − − − 100 y 100 y 100 y − − − − − − − − − − −
Ghana 20 y 19 y 21 y 5 21 2 71 71 70 4 1 − 93 x 20 35 94 x,y 94 x,y 94 x,y − 10 x
Greece − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Grenada − − − − − − − − − − − − − − − − − − − −
Guatemala − − − 6 30 10 96 y − − − − − − 12 14 − − − 1 4
Guinea 24 24 25 19 51 2 75 75 75 97 45 38 22 − 60 89 90 89 − −
Guinea-Bissau 36 36 37 6 24 2 24 24 24 45 29 − 81 37 40 82 83 82 − −
Guyana 11 10 12 4 30 9 89 88 89 − − − − 14 10 70 74 65 − −
Haiti 36 y 44 y 26 y 2 15 2 85 84 85 − − − − 15 23 83 84 82 − 5
Holy See − − − − − − − − − − − − − − − − − − − −
Honduras − − − 8 34 12 94 94 94 − − − − 18 15 − − − − 5
Hungary − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Iceland − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
India − − − 7 27 4 80 79 80 − − − − 35 41 − − − − 1
Indonesia − − − 1 11 5 72 y − − − 49 y − − 48 y 45 − − − − −
Iran (Islamic Republic of) − − − 3 x 17 x − 99 y 99 y 99 y − − − − − − − − − − −
Iraq 6 y 6 y 6 y 7 28 − 99 99 99 7 1 − 94 − 31 81 82 80 − −
Ireland − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Israel − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Italy − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Jamaica 3 3 2 1 x 8 x − 98 − − − − − − − 17 85 x,y 87 x,y 82 x,y − 2 y
Japan − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Jordan 2 2 1 0 8 − 99 99 99 − − − − 64 y 63 y 90 y 91 y 89 y − −
Kazakhstan − − − 0 7 0 x 100 100 100 − − − − − 8 53 55 50 − −
Kenya − − − 4 23 3 67 67 66 21 3 89 93 37 45 − − − 2 4
Kiribati − − − 3 x 20 x 5 x 94 x 95 x 93 x − − − − 65 x 77 x 81 x,y − − − −
Kuwait − − − − − − − − − − − − − − − − − − − −
Kyrgyzstan 16 18 14 1 12 0 98 98 98 − − − − − 22 57 60 54 − −
Lao People's Democratic Republic 12 11 14 7 33 11 73 73 73 − − − − 17 30 69 70 68 − −
Latvia − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Lebanon − − − 1 x 6 x − 100 x 100 x 100 x − − − − − 22 x,y 82 x,y 82 x,y 82 x,y − −
Lesotho − − − 1 17 1 43 42 44 − − − − 49 48 − − − − −
Liberia 14 15 13 9 36 5 25 y 25 y 24 y 44 − − 55 29 45 90 x,y 90 x,y 90 x,y − 4 x
Libya − − − − − − − − − − − − − − − − − − − −
Liechtenstein − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Lithuania − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Luxembourg − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Madagascar − − − 12 41 13 83 83 83 − − − − 44 47 − − − − −
Malawi 19 20 19 9 42 7 6 y 6 y 5 y − − − − 24 21 72 73 72 − 4
Malaysia − − − − − − − − − − − − − − − 71 y 74 y 67 y − −
Maldives − − − 0 x 4 x 1 x 93 x 93 x 92 x − − − − 33 y 35 y − − − − −
Mali 37 40 35 18 50 3 87 88 87 83 73 22 x 14 54 68 73 73 73 − −
Malta − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Marshall Islands − − − 6 x 26 x 12 x 84 85 82 − − − − 71 x 47 x − − − − −
Mauritania 17 y 17 y 18 y 18 37 2 66 y 66 y 66 y 67 51 19 x 50 18 26 80 80 80 − −
Mauritius − − − − − − − − − − − − − − − − − − − −
Mexico 5 6 4 4 26 − 95 96 95 − − − − − 6 63 63 63 − −
Micronesia (Federated States of) − − − − − − − − − − − − − − − − − − − −
Monaco − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Mongolia 17 18 15 0 5 3 99 99 99 − − − − 9 x 14 x 49 52 46 − −
Montenegro 9 10 9 1 5 0 99 100 99 − − − − 5 2 69 73 66 − −
Montserrat − − − − − − 100 y 100 y 100 y − − − − − − − − − − −
Morocco − − − 1 x 13 x − 96 y − − − − − − − 64 x 91 x,y 92 x,y 90 x,y − −
Mozambique − − − 17 53 10 55 54 56 − − − − 21 14 − − − 0 2
Myanmar − − − 2 16 5 81 82 81 − − − − 57 53 77 y 80 y 75 y − 1
Namibia − − − 2 7 1 78 y − − − − − − 30 28 − − − − 1
Nauru − − − 2 x 27 x 12 x 96 − − − − − − − − − − − − −
Nepal 22 20 23 7 40 10 56 57 55 − − − − 31 33 82 83 81 − 3
 234 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 11. CHILD PROTECTION

Female genital mutilation (%)+ Justification of

Child marriage (%)+ 2010–2018* wife-beating
2012–2018* prevalence attitudes among Sexual violence
Child labour (%)+ Birth registration (%)+ want the adolescents (%)+ Violent discipline (%)+ in childhood (%)
2010–2018* female male 2010–2018* practice to stopc 2012–2018* 2012–2018* 2012–2018*
Countries married married married
and areas total male female by 15 by 18 by 18 total male female womena girlsb male female male female total male female male female

Netherlands − − − − − − 100 v 100 v 100 v − − − − − − − − − − −

New Zealand − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Nicaragua − − − 10 35 19 85 − − − − − − − 19 x,y − − − − −
Niger 34 y 34 y 34 y 28 76 6 64 65 62 2 2 y 91 82 41 54 82 y 82 y 81 y − −
Nigeria 31 32 31 18 44 3 47 47 47 18 13 62 68 25 30 85 86 84 − 4
Niue − − − − − − − − − − − − − − − − − − − −
North Macedonia 8 y 8 y 7 y 1 x 7 x − 100 100 100 − − − − − 14 x 69 x,y 71 x,y 67 x,y − −
Norway − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Oman − − − 1 4 − 100 y 100 y 100 y − − − − − 10 − − − − −
Pakistan − − − 3 21 3 34 34 33 − − − − 58 p,y 51 y − − − − −
Palau − − − − − − − − − − − − − − − − − − − −
Panama − − − 7 26 − 96 95 96 − − − − − 9 45 47 43 − 3
Papua New Guinea − − − 2 x 21 x 5 x − − − − − − − − − − − − − −
Paraguay 18 20 13 4 22 − 69 y 69 y 69 y − − − − − 7 52 55 49 − −
Peru 15 14 15 3 19 − 98 y − − − − − − − − − − − − −
Philippines − − − 2 17 3 x 92 92 91 − − − − − 12 − − − − 2
Poland − − − − − − 100 y 100 y 100 y − − − − − − − − − − −
Portugal − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Qatar − − − 0 4 1 100 y 100 y 100 y − − − − 22 6 y 50 y 53 y 46 y − −
Republic of Korea − − − − − − − − − − − − − − − − − − − −
Republic of Moldova − − − 0 12 1 100 99 100 − − − − 14 13 76 y 77 y 74 y − 5 x
Romania − − − − − − − − − − − − − − − − − − − −
Russian Federation − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Rwanda 19 y 17 y 21 y 0 7 1 56 56 56 − − − − 24 45 − − − 0 10
Saint Kitts and Nevis − − − − − − − − − − − − − − − − − − − −
Saint Lucia 3 y 5 y 2 y 1 8 − 92 91 93 − − − − − 15 68 y 71 y 64 y − −
Saint Vincent and the Grenadines − − − − − − − − − − − − − − − − − − − −
Samoa − − − 1 11 2 59 59 58 − − − − 28 34 − − − − −
San Marino − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Sao Tome and Principe 18 17 19 8 35 3 95 96 95 − − − − 19 24 80 80 79 − 3 x
Saudi Arabia − − − − − − − − − − − − − − − − − − − −
Senegal 23 27 19 8 29 1 77 79 76 24 14 79 81 43 48 − − − − 2
Serbia 7 8 6 0 3 1 x 99 99 100 − − − − − 2 43 44 42 − −
Seychelles − − − − − − − − − − − − − − − − − − − −
Sierra Leone 39 y 39 y 38 y 13 30 7 81 82 81 86 8 40 27 29 44 87 87 86 0 2
Singapore − − − − − − − − − − − − − − − − − − − −
Slovakia − − − − − − 100 y 100 y 100 y − − − − − − − − − − −
Slovenia − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Solomon Islands 18 y 17 y 19 y 6 21 4 88 87 89 − − − − 60 78 86 y 86 y 85 y − −
Somalia − − − 8 x 45 x − 3 x 3 x 3 x 98 x 46 x,y − 33 x − 75 x,y − − − − −
South Africa 4 y 4 y 3 y 1 x 6 x − 89 y − − − − − − 14 7 − − − − −
South Sudan − − − 9 x 52 x − 35 35 36 − − − − − 72 x − − − − −
Spain − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Sri Lanka − − − 1 10 − 97 x 97 x 97 x − − − − − 54 x,y − − − − −
State of Palestine 9 y 10 y 8 y 1 15 − 96 − − − − − − − − 92 93 92 − −
Sudan 18 20 16 12 34 − 67 69 66 87 30 64 53 − 36 64 65 63 − −
Suriname 4 y 4 y 4 y 5 x 19 x − 99 99 99 − − − − − 19 x 86 x,y 87 x,y 85 x,y − −
Sweden − − − − − − 100 v 100 v 100 v − − − − − − − − − 4 y 13 y
Switzerland − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Syrian Arab Republic − − − 3 x 13 x − 96 x 96 x 96 x − − − − − − 89 x,y 90 x,y 88 x,y − −
Tajikistan − − − 0 9 − 96 96 96 − − − − − 44 69 70 68 − 0
Thailand − − − 4 23 10 100 y 100 y 100 y − − − − 9 9 75 77 73 − −
Timor-Leste − − − 3 15 1 60 60 61 − − − − 48 69 − − − − 3
Togo 23 23 22 6 22 3 78 79 77 5 0 96 95 19 26 81 81 80 − 4
Tokelau − − − − − − − − − − − − − − − − − − − −
Tonga − − − 0 6 6 93 94 93 − − − − 29 27 − − − − −
Trinidad and Tobago 1 y 1 y 1 y 3 x 11 x − 97 97 97 − − − − − 8 x 77 x,y 79 x,y 75 x,y − 25 y
Tunisia 2 y 3 y 1 y 0 2 − 99 99 100 − − − − − 27 93 y 94 y 92 y − −
Turkey − − − 1 15 − 99 y 99 y 99 y − − − − − 10 − − − − −
Turkmenistan 0 0 0 0 6 − 100 100 100 − − − − − 17 37 y 39 y 34 y − −
Turks and Caicos Islands − − − − − − − − − − − − − − − − − − − −
Tuvalu − − − 0 x 10 x 0 x 50 x 49 x 51 x − − − − 83 x 69 x − − − − −
Uganda 18 17 19 7 34 6 32 32 32 0 1 − 83 53 58 85 85 85 1 5
 S TAT I S T I C A L TA B L E S » 2 3 5

TABLE 11. CHILD PROTECTION

Female genital mutilation (%)+ Justification of

Child marriage (%)+ 2010–2018* wife-beating
2012–2018* prevalence attitudes among Sexual violence
Child labour (%)+ Birth registration (%)+ want the adolescents (%)+ Violent discipline (%)+ in childhood (%)
2010–2018* female male 2010–2018* practice to stopc 2012–2018* 2012–2018* 2012–2018*
Countries married married married
and areas total male female by 15 by 18 by 18 total male female womena girlsb male female male female total male female male female

Ukraine 3 y 3 y 3 y 0 9 4 100 100 100 − − − − 2 2 61 y 68 y 55 y − 2 x

United Arab Emirates − − − − − − 100 y 100 y 100 y − − − − − − − − − − −
United Kingdom − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
United Republic of Tanzania 24 25 24 5 31 4 26 28 25 10 0 89 x 95 50 59 − − − − 7
United States − − − − − − 100 v 100 v 100 v − − − − − − − − − − −
Uruguay 4 5 3 1 25 − 100 100 100 − − − − − 3 55 y 58 y 51 y − −
Uzbekistan − − − 0 x 7 x 1 x 100 x 100 x 100 x − − − − 63 x 63 x − − − − −
Vanuatu 16 y 15 y 16 y 3 21 5 43 y 44 y 43 y − − − − 63 56 84 y 83 y 84 y − −
Venezuela (Bolivarian Republic of) − − − − − − 81 y − − − − − − − − − − − − −
Viet Nam 13 13 14 1 11 3 x 96 96 96 − − − − − 28 68 72 65 − −
Yemen − − − 9 32 − 31 31 30 19 15 − 75 − 49 79 y 81 y 77 y − −
Zambia 23 23 23 6 31 2 11 12 11 − − − − 41 49 − − − − 5
Zimbabwe − − − 4 32 1 38 − − − − − − 49 54 63 63 62 − 6

SUMMARY
East Asia and Pacific − − − 1 7 − − − − − − − − − − − − − − −
Europe and Central Asia − − − − − − 100 100 100 − − − − − − − − − − −
Eastern Europe and Central
− − − 1 11 − 99 99 99 − − − − − 11 − − − − −
Asia
Western Europe − − − − − − 100 100 100 − − − − − − − − − − −
Latin America and Caribbean − − − 4 25 − 94 − − − − − − − − − − − − −
Middle East and North Africa 5 5 4 4 18 − 92 92 92 − − − − − 44 87 88 86 − −
North America − − − − − − 100 100 100 − − − − − − − − − − −
South Asia − − − 8 30 4 65 65 65 − − − − 39 42 − − − − 2
Sub-Saharan Africa 29 29 29 12 37 4 46 45 44 35 13 − 73 36 44 81 82 81 − 6
Eastern and Southern Africa 27 27 26 9 34 5 40 36 35 42 11 − 81 35 44 − − − − 5
West and Central Africa 31 30 31 15 40 4 53 53 52 29 15 68 66 37 45 83 84 82 − 6
Least developed countries 29 29 29 12 39 6 40 40 40 − − − − 43 48 80 81 79 − 5
World − − − 5 21 − 73 75 74 − − − − 37 38 − − − − −
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES

Child labour – Percentage of children 5–17 years old involved
in child labour at the moment of the survey. A child is
considered to be involved in child labour under the following
conditions: (a) children 5–11 years old who, during the
reference week, did at least one hour of economic activity and/
or more than 21 hours of unpaid household services, (b)
children 12–14 years old who, during the reference week, did
at least 14 hours of economic activity and/or more than 21
hours of unpaid household services, (c) children 15–17 years
old who, during the reference week, did at least 43 hours of
economic activity.
Child marriage – Percentage of women 20–24 years old who
were first married or in union before they were 15 years old;
percentage of women 20–24 years old who were first married
or in union before they were 18 years old; percentage of men
20–24 years old who were first married or in union before they
were 18 years old.
Birth registration – Percentage of children under age 5 who
were registered at the moment of the survey. The numerator of
this indicator includes children reported to have a birth
certificate, regardless of whether or not it was seen by the
interviewer, and those without a birth certificate whose mother
or caregiver says the birth has been registered.
Female genital mutilation (FGM) – (a) Women: percentage Child labour – Demographic and Health
of women 15–49 years old who have undergone FGM; (b) girls: Surveys (DHS), Multiple Indicator Cluster
percentage of girls 0–14 years old who have undergone FGM Surveys (MICS) and other national
(as reported by their mothers); (c) want the practice to stop: surveys. Last update: March 2019.
percentage of women and men 15–49 years old who have Child marriage – DHS, MICS and other
heard about FGM and think the practice should stop. national surveys. Last update: (female)
Justification of wife-beating among adolescents – March 2019; (male) August 2019.
Percentage of girls and boys 15–19 years old who consider a
Birth registration – DHS, MICS, other
husband to be justified in hitting or beating his wife for at least national surveys, censuses and vital
one of the specified reasons, i.e., if his wife burns the food,
registration systems. Last update: March
argues with him, goes out without telling him, neglects the 2019.
children or refuses sexual relations.
Female genital mutilation – DHS, MICS
Violent discipline – Percentage of children 1–14 years old and other national surveys. Last update:
who experience any violent discipline (psychological
(a) March 2019; (b, c) August 2019.
aggression and/or physical punishment) in the past month.
Sexual violence in childhood – Percentage of women
NOTES
and men 18–29 years old who experienced sexual violence by
age 18. – Data not available.
p Based on small denominators
(typically 25–49 unweighted cases).
No data based on fewer than 25
unweighted cases are displayed.
v Estimates of 100% were assumed
given that civil registration systems
in these countries are complete and
all vital events (including births) are
registered. Source: United Nations,
Department of Economic and Social
Affairs, Statistics Division, last
update December 2017.
x Data refer to years or periods other
than those specified in the column
heading. Such data are not included
in the calculation of regional and
global averages.
y Data differ from the standard defini-
tion or refer to only part of a country.
Justification of wife-beating among
adolescents – DHS, MICS and other
national surveys. Last update: August
2019.
Violent discipline – DHS, MICS and
other national surveys. Last update: March
2019.
Sexual violence in childhood – DHS
and other national surveys. Last update:
March 2019.
If they fall within the noted reference
period, such data are included in the
calculation of regional and global
averages.
+ A more detailed explanation of the
methodology and the changes in
calculating these estimates can be
found in the General Note on the
Data, page 180.
* Data refer to the most recent year
available during the period specified
in the column heading.
Italicized data are from older
sources than data presented for other
indicators on the same topic within
this table. Such discrepancies may be
due to an indicator being unavailable
in the latest data source, or to the
databases for each indicator having
been updated as of different dates.
 236 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 12. SOCIAL PROTECTION AND EQUITY

Mothers with Proportion of Distribution of social protection benefits Share of household income
newborns children covered (%, 2010–2016*) (%, 2010–2018*) Palma index GDP per
Countries receiving cash
benefit (%)
by social
protection
Gini
coefficient
of income capita
inequality (current US$)
and areas 2010–2018* 2010–2018* bottom 40% top 20% bottom 20% bottom 40% top 20% bottom 20% 2010–2018* 2010–2018* 2010–2018*

Afghanistan − − − − − − − − − − 556.3
Albania − − 28.2 30.3 13.5 − 37.8 8.9 29.0 − 4532.9
Algeria 11.2 − − − − − 37.2 9.4 27.6 − 4048.3
Andorra − − − − − − − − − − 39134.4
Angola − − − − − − − − − 2.2 4095.8
Anguilla − − − − − − − − − − −
Antigua and Barbuda 40.0 − − − − − − − − − 15824.7
Argentina 34.0 84.6 16.7 39.6 6.7 15.3 46.0 5.2 40.6 2.4 14591.9
Armenia 61.0 21.4 37.7 23.1 17.8 20.8 42.4 8.4 33.6 1.2 3914.5
Australia − 100.0 − − − 18.8 43.0 6.8 35.8 − 54093.6
Austria 100.0 100.0 − − − 21.1 38.4 7.9 30.5 − 47380.8
Azerbaijan 14.0 − 29.4 32.4 17.3 − − − − − 4147.1
Bahamas − − − − − − − − − − 31857.9
Bahrain − − − − − − − − − − 23715.5
Bangladesh 20.9 29.4 20.0 52.7 8.7 21.0 41.4 8.6 32.4 1.3 1564.0
Barbados − − − − − − − − − − 16327.6
Belarus − − 37.3 21.8 16.9 24.1 35.5 9.9 25.4 0.9 5761.7
Belgium 100.0 100.0 − − − 22.6 36.5 8.6 27.7 − 43507.2
Belize − − 40.4 32.5 18.9 − − − − − 4956.8
Benin − − − − − − 52.1 3.2 47.8 − 827.4
Bhutan − − 16.5 41.1 1.3 − 44.4 6.7 37.4 1.8 3390.7
Bolivia (Plurinational State of) 51.5 65.0 29.3 37.3 14.5 − − − − − 3351.1
Bosnia and Herzegovina − − 27.8 29.0 11.8 − 40.7 7.5 33.0 − 5394.6
Botswana − 5.5 28.5 28.6 12.8 − 58.5 3.9 53.3 − 7893.7
Brazil 45.0 96.8 12.6 51.7 4.2 − 57.8 3.2 53.3 4.3 9880.9
British Virgin Islands − − − − − − − − − − −
Brunei Darussalam − − − − − − − − − − 28572.1
Bulgaria 100.0 48.6 − − − 17.8 43.9 6.0 37.4 − 8228.0
Burkina Faso 0.4 − 3.8 69.5 1.5 − 44.3 8.3 35.3 1.9 642.0
Burundi − − − − − − 46.3 6.9 38.6 − 293.0
Cabo Verde − 31.5 − − − − − − − − 3295.3
Cambodia 1.5 − 8.7 46.9 0.1 − − − − 1.5 1385.3
Cameroon 0.6 0.4 2.9 59.4 0.7 − 51.7 4.5 46.6 − 1421.6
Canada 100.0 39.7 − − − 18.9 40.7 6.6 34.0 − 45069.9
Central African Republic − 1.0 − − − − − − − − 471.6
Chad − − 15.2 45.7 1.6 − 48.8 4.9 43.3 − 664.3
Chile 44.0 93.1 17.1 48.8 7.6 − 52.9 5.2 46.6 3.5 15037.4
China 64.9 2.2 9.2 51.1 3.0 17.0 45.4 6.4 38.6 2.1 8759.0
Colombia − 27.3 6.7 71.7 3.0 12.4 54.8 4.1 49.7 4.5 6375.9
Comoros − − − − − − 50.4 4.5 45.3 − 1312.4
Congo − − − − − − 53.7 4.2 48.9 − 1702.6
Cook Islands − − − − − − − − − − −
Costa Rica − 17.7 13.1 61.2 5.3 12.8 54.0 4.4 48.3 3.3 11752.5
Côte d'Ivoire − − 16.3 52.8 6.6 − 47.8 5.7 41.5 − 1557.2
Croatia 100.0 − 29.1 30.5 13.1 20.4 38.4 7.3 31.1 − 13383.7
Cuba − − − − − − − − − − 8541.2
Cyprus 100.0 60.3 − − − 20.0 42.1 7.9 34.0 − 25760.8
Czechia 100.0 − − − − 24.4 35.9 9.7 25.9 − 20379.9
Democratic People's Republic of Korea − − − − − − − − − − −
Democratic Republic of the Congo − 1.3 8.2 63.9 3.4 − 48.4 5.5 42.1 − 467.1
Denmark 100.0 100.0 − − − 23.3 37.7 9.4 28.2 − 57218.9
Djibouti − − 22.3 43.3 10.3 − 47.6 5.4 41.6 − 1953.9
Dominica − − − − − − − − − − 6951.3
Dominican Republic − − 20.4 44.6 8.5 13.9 51.5 4.9 45.7 2.7 7222.6
Ecuador − 6.7 14.0 61.6 6.7 14.1 50.1 4.7 44.7 3.1 6213.5
Egypt 100.0 − 15.6 53.5 7.2 21.9 41.5 9.1 31.8 − 2440.5
El Salvador − − 7.2 70.9 2.4 17.4 44.7 6.4 38.0 3.0 3902.2
Equatorial Guinea − − − − − − − − − − 9738.4
Eritrea − − − − − − − − − − 811.4
Estonia 100.0 100.0 − − − 20.0 40.4 7.5 32.7 − 20200.4
Eswatini − − 24.7 36.9 13.7 − − − − 3.5 3941.9
Ethiopia − − − − − 17.6 46.7 6.6 39.1 1.4 768.0
Fiji − − 22.8 34.3 9.5 − 44.7 7.5 36.7 2.2 6006.4
Finland 100.0 100.0 − − − 23.4 36.7 9.4 27.1 − 45804.7
 S TAT I S T I C A L TA B L E S » 2 3 7

TABLE 12. SOCIAL PROTECTION AND EQUITY

Mothers with Proportion of Distribution of social protection benefits Share of household income
newborns children covered (%, 2010–2016*) (%, 2010–2018*) Palma index GDP per
Countries receiving cash
benefit (%)
by social
protection
Gini
coefficient
of income capita
inequality (current US$)
and areas 2010–2018* 2010–2018* bottom 40% top 20% bottom 20% bottom 40% top 20% bottom 20% 2010–2018* 2010–2018* 2010–2018*

France 100.0 100.0 − − − 20.7 40.9 7.9 32.7 − 38679.1

Gabon − − − − − − 44.4 6.0 38.0 − 7212.5
Gambia − − 7.6 58.7 3.4 19.0 43.6 7.4 35.9 − 672.8
Georgia 24.0 − 39.8 19.0 20.4 17.4 44.5 6.3 37.9 2.1 4045.4
Germany 100.0 100.0 − − − 20.7 39.7 7.8 31.7 − 44681.1
Ghana 41.7 5.6 3.0 48.3 0.7 − 48.6 4.7 43.5 − 2025.9
Greece 100.0 − − − − 17.7 41.8 5.9 36.0 − 18883.5
Grenada − − − − − − − − − − 10163.6
Guatemala 14.0 3.1 2.3 83.2 1.0 − 53.6 4.5 48.3 − 4470.6
Guinea − − 7.6 54.3 4.1 − 41.5 7.6 33.7 − 821.7
Guinea-Bissau − − − − − 12.8 56.7 4.5 50.7 − 736.7
Guyana − − − − − − − − − − 4586.1
Haiti − − 0.4 97.3 0.0 − 47.1 5.5 41.1 − 765.6
Holy See − − − − − − − − − − −
Honduras − − 16.6 61.4 7.6 11.0 54.6 3.2 50.5 5.2 2432.9
Hungary 100.0 100.0 − − − 21.1 38.4 7.8 30.4 − 14278.9
Iceland 100.0 − − − − 23.2 37.3 9.4 27.8 − 71314.8
India 41.0 − 42.9 16.5 22.3 − 44.4 8.1 35.7 1.4 1981.5
Indonesia − − 63.2 4.1 35.5 17.5 45.2 6.8 38.1 1.7 3836.9
Iran (Islamic Republic of) 14.0 − − − − − 46.7 6.1 40.0 − 5627.7
Iraq − − 21.5 41.5 9.1 − 38.5 8.8 29.5 − 5143.7
Ireland 100.0 100.0 − − − 20.9 40.2 8.0 31.8 − 68941.8
Israel − − − − − 15.9 44.2 5.2 38.9 − 40543.6
Italy 100.0 − − − − 18.0 41.3 5.9 35.4 − 32155.2
Jamaica − − 29.0 34.1 14.6 − − − − − 5060.5
Japan − − − − − − − − − − 38332.0
Jordan − − 25.1 38.8 12.2 20.3 42.4 8.2 33.7 1.5 4168.6
Kazakhstan 44.6 100.0 23.6 37.9 10.7 23.4 37.4 9.8 27.5 1.1 9030.3
Kenya − 8.1 30.9 31.3 14.6 − 47.5 6.2 40.8 − 1568.2
Kiribati − − − − − − − − − − 1625.6
Kuwait − − − − − − − − − − 29474.5
Kyrgyzstan 23.8 17.8 31.0 30.2 15.5 23.6 37.4 9.9 27.3 1.3 1242.8
Lao People's Democratic Republic − − − − − − 44.6 7.6 36.4 − 2423.8
Latvia 100.0 100.0 35.1 19.5 15.4 19.4 41.5 7.1 34.2 1.4 15684.6
Lebanon − − − − − − 40.0 7.9 31.8 − 7838.3
Lesotho − 10.4 − − − 9.6 58.2 2.8 54.2 − 1232.8
Liberia − − 37.5 21.5 20.8 − 42.8 7.2 35.3 − 698.7
Libya − − − − − − − − − − 5792.1
Liechtenstein 100.0 − − − − − − − − − 165028.2
Lithuania 100.0 − 39.9 18.9 20.2 17.7 44.1 6.1 37.4 − 16809.6
Luxembourg 100.0 − − − − 19.3 41.0 7.2 33.8 − 104498.7
Madagascar − − − − − 15.7 49.4 5.7 42.6 2.3 448.4
Malawi − 9.8 22.7 38.5 11.0 16.2 51.7 6.4 44.7 2.3 356.7
Malaysia − − 22.9 37.2 10.2 − 47.3 5.8 41.0 2.6 10117.6
Maldives − − 37.0 27.3 18.7 − − − − − 9801.6
Mali − 5.4 6.1 67.0 0.4 − − − − 1.3 828.6
Malta 100.0 − − − − 21.9 38.1 8.5 29.4 − 27241.1
Marshall Islands − − − − − − − − − − 3516.7
Mauritania − − 18.2 42.7 7.7 − 40.2 7.5 32.6 − 1161.8
Mauritius − − 26.6 35.6 12.0 − 43.9 7.4 35.8 − 10484.9
Mexico 9.6 28.4 16.4 58.2 7.7 15.5 50.1 5.7 43.4 2.7 9281.1
Micronesia (Federated States of) − − − − − − 46.0 5.5 40.1 − 3018.4
Monaco − − − − − − − − − − 166726.1
Mongolia 100.0 100.0 33.0 24.9 15.2 20.4 40.6 8.0 32.3 − 3671.9
Montenegro − − 24.1 37.6 10.5 20.8 40.5 8.5 31.9 1.0 7784.1
Montserrat − − − − − − − − − − −
Morocco − − − − − − 47.0 6.7 39.5 − 3036.2
Mozambique 0.2 − 13.4 55.6 5.3 − 59.5 4.2 54.0 − 441.6
Myanmar 0.7 − − − − − 45.7 7.3 38.1 − 1249.8
Namibia − − − − − − 63.7 2.8 59.1 − 5646.5
Nauru − − − − − − − − − − 8844.4
Nepal − − 17.1 47.7 5.9 20.4 41.5 8.3 32.8 1.3 900.6
Netherlands 100.0 100.0 − − − 22.8 37.3 8.9 28.2 − 48482.8
New Zealand − − − − − − − − − − 42260.1
 238 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 12. SOCIAL PROTECTION AND EQUITY

Mothers with Proportion of Distribution of social protection benefits Share of household income
newborns children covered (%, 2010–2016*) (%, 2010–2018*) Palma index GDP per
Countries receiving cash
benefit (%)
by social
protection
Gini
coefficient
of income capita
inequality (current US$)
and areas 2010–2018* 2010–2018* bottom 40% top 20% bottom 20% bottom 40% top 20% bottom 20% 2010–2018* 2010–2018* 2010–2018*

Nicaragua − − 9.3 56.1 2.5 − 52.1 5.1 46.2 − 2168.2

Niger − 4.2 12.2 51.6 5.5 − 42.4 7.8 34.3 − 375.9
Nigeria 0.1 − 8.7 68.6 2.2 − − − − 3.0 1968.6
Niue − − − − − − − − − − −
North Macedonia − − − − − 17.3 41.1 5.6 35.6 2.3 5417.6
Norway 100.0 100.0 − − − 23.1 36.5 9.0 27.5 − 75704.2
Oman − − − − − − − − − − 15170.4
Pakistan − − 11.9 58.2 5.1 21.1 42.8 8.9 33.5 − 1466.8
Palau − − − − − − − − − − 16274.9
Panama − 37.3 14.3 55.1 5.7 11.5 54.2 3.4 49.9 3.6 15166.1
Papua New Guinea − − 33.0 52.4 4.5 − − − − − 2640.2
Paraguay 3.0 32.8 11.8 61.2 4.6 13.2 54.0 4.6 48.8 3.7 5680.6
Peru − − 10.3 63.2 5.4 14.4 48.4 4.7 43.3 2.9 6700.8
Philippines 11.0 13.6 26.1 46.7 12.9 − 47.3 6.6 40.1 2.2 2981.9
Poland 100.0 100.0 26.1 30.0 11.5 21.3 39.5 8.5 30.8 1.3 13861.1
Portugal 100.0 93.1 − − − 18.7 42.7 6.7 35.5 − 21291.4
Qatar − − − − − − − − − − 61264.4
Republic of Korea − − − − − 20.3 39.0 7.3 31.6 − 29742.8
Republic of Moldova − − 36.5 20.8 15.9 24.1 36.1 10.0 25.9 1.3 2724.5
Romania 100.0 100.0 25.1 32.3 9.6 16.9 40.7 5.1 35.9 1.0 10793.0
Russian Federation 63.0 100.0 28.8 23.8 9.5 18.0 45.3 6.9 37.7 1.9 10750.6
Rwanda − − 27.0 42.9 12.7 15.8 50.8 6.0 43.7 3.2 762.5
Saint Kitts and Nevis − − − − − − − − − − −
Saint Lucia − − − − − − − − − − −
Saint Vincent and the Grenadines − − − − − − − − − − 7149.6
Samoa − − 25.1 42.2 11.0 − 46.4 6.8 38.7 − 4307.8
San Marino − − − − − − − − − − 48494.6
Sao Tome and Principe − − − − − 21.1 39.5 8.4 30.8 − 1811.0
Saudi Arabia − − − − − − − − − − 20803.7
Senegal − 4.0 3.2 66.3 1.2 − 46.9 6.1 40.3 1.9 1367.2
Serbia − − 30.1 28.0 13.4 22.5 37.7 9.0 28.5 1.1 6284.2
Seychelles − − − − − − 53.0 5.4 46.8 − 15683.7
Sierra Leone − − − − − − 42.4 7.9 34.0 1.5 499.4
Singapore − − − − − − − − − − 60297.8
Slovakia 100.0 100.0 27.9 18.4 10.5 23.1 35.0 8.5 26.5 0.9 17579.3
Slovenia 96.0 79.4 − − − 24.1 35.1 9.6 25.4 − 23449.6
Solomon Islands − − − − − − 44.6 7.0 37.1 − 2077.1
Somalia − − − − − − − − − − 488.6
South Africa − 75.1 37.1 31.6 18.5 7.2 68.2 2.4 63.0 7.1 6120.5
South Sudan − − 17.1 55.9 3.9 − − − − − 283.5
Spain 100.0 100.0 − − − 17.5 42.1 5.8 36.2 − 28208.3
Sri Lanka − − 15.7 49.3 6.0 − 47.6 7.0 39.8 1.6 4104.6
State of Palestine − − 39.3 13.1 18.8 19.2 41.1 7.3 33.7 1.5 3254.5
Sudan − − 33.0 22.9 18.0 − − − − 1.4 3015.0
Suriname − − − − − − − − − − 5379.1
Sweden 100.0 100.0 − − − 22.1 37.6 8.2 29.2 − 53253.5
Switzerland 100.0 100.0 − − − 20.3 40.2 7.8 32.3 − 80333.4
Syrian Arab Republic − − − − − − − − − − −
Tajikistan 59.5 6.4 35.3 25.8 17.0 − 41.7 7.4 34.0 1.2 806.0
Thailand − 18.9 17.5 48.9 8.4 18.4 44.1 7.3 36.5 1.8 6578.2
Timor-Leste − 30.7 8.8 88.0 5.3 − 38.4 9.4 28.7 − 2000.6
Togo − 49.0 2.3 86.2 0.0 − 48.6 5.0 43.1 1.8 619.1
Tokelau − − − − − − − − − − −
Tonga − − 5.0 44.9 0.0 − 45.4 6.8 37.6 − 4217.5
Trinidad and Tobago − − − − − − − − − − 16076.1
Tunisia − 48.3 37.3 19.7 19.8 20.1 40.9 7.8 32.8 1.5 3494.3
Turkey − − 16.7 38.7 6.1 15.6 48.3 5.7 41.9 1.9 10499.7
Turkmenistan − − − − − − − − − − 6587.1
Turks and Caicos Islands − − − − − − − − − − 25933.6
Tuvalu − − − − − 17.4 46.4 6.6 39.1 − 3572.6
Uganda − − 11.4 68.2 0.9 − 49.8 6.1 42.8 2.3 631.5
Ukraine 100.0 100.0 32.0 25.7 14.0 24.5 35.1 10.1 25.0 0.9 2640.7
United Arab Emirates − − − − − − − − − − 40325.4
United Kingdom 100.0 100.0 − − − 19.7 40.6 7.5 33.2 − 39932.1
United Republic of Tanzania 0.3 − 7.0 70.8 3.1 − 45.8 7.4 37.8 − 1004.8
 S TAT I S T I C A L TA B L E S » 2 3 9

TABLE 12. SOCIAL PROTECTION AND EQUITY

Mothers with Proportion of Distribution of social protection benefits Share of household income
newborns children covered (%, 2010–2016*) (%, 2010–2018*) Palma index GDP per
Countries receiving cash
benefit (%)
by social
protection
Gini
coefficient
of income capita
inequality (current US$)
and areas 2010–2018* 2010–2018* bottom 40% top 20% bottom 20% bottom 40% top 20% bottom 20% 2010–2018* 2010–2018* 2010–2018*

United States − − − − − 15.2 46.9 5.0 41.5 − 59927.9

Uruguay 100.0 66.2 11.9 50.7 3.2 16.5 45.8 5.9 39.5 2.5 16437.2
Uzbekistan 16.0 22.0 − − − − − − − − 1826.6
Vanuatu − − − − − 17.8 44.8 6.7 37.6 − 2976.1
Venezuela (Bolivarian Republic of) − − − − − − − − − − 16054.5
Viet Nam 44.5 − 10.6 54.4 3.7 18.8 42.5 6.9 35.3 − 2365.6
Yemen − − − − − − 44.7 7.3 36.7 − 963.5
Zambia − 21.1 1.3 75.5 0.3 8.9 61.3 2.9 57.1 4.8 1534.9
Zimbabwe − − 7.6 58.7 2.2 − 49.7 5.8 43.2 − 1602.4

SUMMARY
East Asia and Pacific 57.8 5.4 17.9 44.5 8.2 17.3 45.1 6.6 38.2 2.0 10,092.7
Europe and Central Asia 85.8 93.2 − − − 19.7 41.4 7.4 33.7 − 23,451.8
Eastern Europe and Central Asia 62.8 84.1 26.8 29.0 10.5 18.9 43.1 7.3 35.4 1.6 8,000.9
Western Europe 100.0 99.6 − − − 20.2 40.1 7.5 32.4 − 36,682.3
Latin America and Caribbean 32.3 62.8 13.3 56.6 5.5 14.5 53.2 4.4 47.8 3.6 9,271.8
Middle East and North Africa 51.6 − − − − − 42.7 7.9 34.3 − 7,497.5
North America 100.0 39.7 − − − 15.6 46.3 5.2 40.7 − 58,411.2
South Asia 38.9 − − 25.7 18.5 21.0 ‡ 43.9 8.2 35.1 1.4 1,864.8
Sub-Saharan Africa − − 13.9 56.5 5.6 14.1 49.7 5.8 43.1 2.8 1,625.3
Eastern and Southern Africa − − 21.8 47.2 9.9 − 51.3 5.7 44.5 2.8 1,879.2
West and Central Africa 4.7 − 8.5 62.8 2.7 − 47.4 5.8 41.0 2.7 1,365.2
Least developed countries 11.1 17.1 14.2 56.7 5.8 18.5 46.0 6.9 38.5 1.7 1,113.8
World 47.1 33.1 24.1 39.5 11.3 18.2 45.6 6.9 38.1 2.0 10,046.2
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES

Mothers with newborns receiving cash benefit (%) –
Proportion of women giving birth covered by maternity benefits:
ratio of women receiving cash maternity benefits to women
giving birth in the same year (estimated based on age-specific
fertility rates published in the UN’s World Population Prospects
or on the number of live births corrected for the share of twin
and triplet births).
Proportion of children covered by social protection –
Proportion of children covered by social protection benefits:
ratio of children/households receiving child or family cash
benefits to the total number of children/households with
children.
Distribution of social protection benefits – Percentage of
benefits going to the 1st quintile, bottom 40% and 5th quintile
relative to the total benefits going to the population. Social
protection coverage includes: providing social assistance
through cash transfers to those who need them, especially
children; benefits and support for people of working age in
case of maternity, disability, work injury or for those without
jobs; and pension coverage for the elderly.
Share of household income – Percentage of income
received by the 20 per cent of households with the highest
income, by the 40 per cent of households with the lowest
income and by the 20 per cent of households with the
lowest income.
Gini coefficient – Gini index measures the extent to which
the distribution of income (or, in some cases, consumption
expenditure) among individuals or households within an
economy deviates from a perfectly equal distribution. A Lorenz
curve plots the cumulative percentages of total income
received against the cumulative number of recipients, starting
with the poorest individual or household. The Gini index
measures the area between the Lorenz curve and a
hypothetical line of absolute equality, expressed as a
percentage of the maximum area under the line. Thus a Gini
index of 0 represents perfect equality, while an index of 100
implies perfect inequality.
Palma index of income inequality – Palma index is defined
as the ratio of the richest 10% of the population’s share of
gross national income divided by the poorest 40%’s share.
GDP per capita (current US$) – GDP per capita is gross
domestic product divided by midyear population. GDP is the
sum of gross value added by all resident producers in the
economy plus any product taxes and minus any subsidies not
included in the value of the products. It is calculated without
making deductions for depreciation of fabricated assets or for
depletion and degradation of natural resources. Data are in
current US dollars.
Mothers with newborns receiving Gini coefficient – World Development
cash benefit (%) – ILO World Social Indicators. Last update: July 2019.
Protection Report, 2017-2019. Last Palma index of income inequality
update: July 2019. – The World Bank. Global Monitor Report,
Proportion of children covered by 2014–2015. Last update: 2015.
social protection – ILO World Social
GDP per capita (current US$) – World
Protection Report, 2017-2019. Last Development Indicators. Last update: July
update: July 2019.
2019.
Distribution of social protection
benefits – The Atlas of Social Protection:
Indicators of Resilience and Equity. Last
update: May 2019.
Share of household income – World
Development Indicators. Last update: July
2019.
NOTES
– Data not available.
* Data refer to the most recent year
available during the period specified
in the column heading.
‡ Excludes India.
 240 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 13. WASH

Households Schools Health care facilities

Basic
Basic waste
Basic sanita- Basic man-
At least basic At least basic water tion hygiene agement
drinking water sanitation Basic hygiene Basic water services Basic sanitation services Basic hygiene services services services services services
services (%) services (%) facilities (%) (%) (%) (%) (%) (%) (%) (%)
2017 2017 2017 2016 2016 2016 2016 2016 2016 2016
Countries second- second- second-
and areas total urban rural total urban rural total urban rural total primary ary total primary ary total primary ary total total total total

Afghanistan 67 96 57 43 62 37 38 64 29 – – – – – – – – – – – – –
Albania 91 92 90 98 98 97 – – – – – – – – – – – – – – – –
Algeria 94 95 89 88 90 82 84 88 73 93 87 98 99 98 100 99 98 99 – – – –
Andorra 100 100 100 100 100 100 – – – 100 100 100 100 100 100 100 100 100 100 – – 100
Angola 56 71 27 50 64 23 27 34 13 – – – – – – – – – – – – –
Anguilla 97 97 – 97 97 – – – – – – – – – – – – – – – – –
Antigua and Barbuda 97 – – 88 – – – – – – – – – – – – – – – – – –
Argentina – 100 – – 96 – – – – – – – 77 77 – – – – – – – –
Armenia 100 100 100 94 100 83 94 97 90 – – – – – – – – – 97 41 69 97
Australia 100 100 100 100 – – – – – 100 100 100 100 100 100 100 100 100 – – – –
Austria 100 100 100 100 100 100 – – – – – – – – – – – – – – – –
Azerbaijan 91 99 82 93 96 88 83 – – 100 100 100 100 100 100 100 100 100 100 48 100 –
Bahamas 99 – – 95 – – – – – – – – – – – – – – – – – –
Bahrain 100 – – 100 – – – – – 100 100 100 100 100 100 100 100 100 – – – –
Bangladesh 97 97 97 48 51 47 35 51 26 74 73 87 59 57 67 44 39 58 70 – – 11
Barbados 98 – – 97 – – – – – 100 100 100 100 100 100 100 100 100 – – – –
Belarus 96 96 98 98 98 96 – – – 100 100 100 100 100 100 100 100 100 – – – –
Belgium 100 100 100 99 99 99 – – – 100 100 100 – – – 100 100 100 – – – –
Belize 98 99 97 88 93 83 90 91 90 – – – – – – – – – – – – –
Benin 66 76 58 16 27 8 11 17 6 – – – – – – – – – 74 – – 26
Bhutan 97 98 97 69 73 67 – – – 59 58 63 76 75 93 – – – – – – –
Bolivia (Plurinational State of) 93 99 78 61 72 36 25 28 19 – – – – – – – – – – – – –
Bosnia and Herzegovina 96 95 97 95 99 92 – – – – – – – – – – – – – – – –
Botswana 90 97 76 77 89 51 – – – – – – – – – – – – – – – –
Brazil 98 100 90 88 93 60 – – – – – – 84 84 – 61 61 65 – – – –
British Virgin Islands 100 – – – – – – – – – – – – – – – – – – – – –
Brunei Darussalam 100 – – – – – – – – – – – – – – – – – – – – –
Bulgaria 99 99 98 86 87 84 – – – – – – – – – – – – – – – –
Burkina Faso 48 80 35 19 39 11 12 23 8 53 55 42 70 74 52 18 18 – 79 – – 31
Burundi 61 90 57 46 42 46 6 20 4 42 39 – 48 35 89 19 20 16 73 – – 84
Cabo Verde 87 93 76 74 80 62 – – – – – – – – – – – – – – – –
Cambodia 79 97 73 59 96 48 66 88 60 – – – 39 48 67 41 49 40 – – – –
Cameroon 60 77 39 39 56 18 9 15 3 34 31 – – – – – – – – – – –
Canada 99 100 99 99 99 99 – – – – – – – – – – – – – – – –
Central African Republic – – – – – – – – – 16 16 – – – – – – – – – – –
Chad 39 70 29 8 30 2 6 18 2 23 19 – – – – – – – – – – 55
Chile 100 100 100 100 100 100 – – – – – – 96 96 – – – – – – – –
China 93 98 86 85 91 76 – – – – – – – – – – – – 91 – 36 –
Colombia 97 100 86 90 93 76 65 73 35 55 – – 61 – – – – – – – – –
Comoros 80 88 77 36 45 32 – – – – – – – – – – – – 21 2 – –
Congo 73 87 46 20 27 6 48 56 32 – – – – – – – – – 37 – – 12
Cook Islands 100 – – 98 – – – – – 100 100 100 100 100 100 100 100 100 – – – –
Costa Rica 100 100 100 98 98 96 – – – 82 85 78 70 68 76 70 68 76 – – – –
Côte d'Ivoire 73 88 58 32 46 18 19 28 10 – – – – – – – – – 57 – – –
Croatia 100 100 100 97 98 95 – – – 51 – – 34 – – 26 – – – – – –
Cuba 95 97 90 93 92 95 85 88 76 – – – – – – – – – – – – –
Cyprus 100 100 100 99 100 98 – – – – – – – – – – – – – – – –
Czechia 100 100 100 99 99 99 – – – – – – – – – – – – 100 95 100 100
Democratic People's Republic of
95 97 90 83 90 72 – – – – – – – – – – – – – – – –
Korea
Democratic Republic of the Congo 43 69 23 20 23 18 4 7 2 – – – – – – – – – – – – 12
Denmark 100 100 100 100 100 100 – – – 100 100 100 100 100 100 100 100 100 – – – –
Djibouti 76 84 47 64 76 19 – – – – – – – – – – – – – – – 35
Dominica – – – – – – – – – 100 100 100 100 100 100 100 100 100 – – – –
Dominican Republic 97 98 90 84 86 74 55 58 42 – – – 90 90 – – – – – – – –
Ecuador 94 100 83 88 91 83 81 84 75 51 40 61 83 83 – 87 80 94 – – – 49
Egypt 99 99 99 94 98 91 90 93 88 – – – 100 100 100 100 100 100 – – – –
El Salvador 97 99 92 87 91 79 91 92 86 84 80 87 – – – – – – – – – –
Equatorial Guinea 65 78 31 66 70 57 – – – – – – – – – – – – – – – –
Eritrea – – – – – – – – – – – – – – – – – – – – – –
 S TAT I S T I C A L TA B L E S » 2 4 1

TABLE 13. WASH

Households Schools Health care facilities

Basic
Basic waste
Basic sanita- Basic man-
At least basic At least basic water tion hygiene agement
drinking water sanitation Basic hygiene Basic water services Basic sanitation services Basic hygiene services services services services services
services (%) services (%) facilities (%) (%) (%) (%) (%) (%) (%) (%)
2017 2017 2017 2016 2016 2016 2016 2016 2016 2016
Countries second- second- second-
and areas total urban rural total urban rural total urban rural total primary ary total primary ary total primary ary total total total total

Estonia 100 100 99 99 99 99 – – – 100 100 100 100 100 100 100 100 100 100 – 100 100
Eswatini 69 97 60 58 51 61 24 48 17 – – – – – – – – – – – – –
Ethiopia 41 80 31 7 20 4 8 23 4 – – – – – – 6 5 7 30 59 – 64
Fiji 94 98 89 95 95 95 – – – 88 – – 76 – – 61 – – – – – –
Finland 100 100 100 99 99 99 – – – 100 100 100 100 100 100 100 100 100 – – – –
France 100 100 100 99 99 99 – – – 100 100 100 100 100 100 100 100 100 – – – –
Gabon 86 90 55 47 49 37 – – – – – – – – – – – – – – – –
Gambia 78 87 63 39 45 30 8 12 1 – – – 82 83 80 – – – – – – –
Georgia 98 100 96 90 95 83 – – – 74 – – 60 – – 12 – – – – – –
Germany 100 100 100 99 99 99 – – – 100 100 100 100 100 100 100 100 100 – – – –
Ghana 81 93 68 18 24 12 41 45 37 – – – – – – – – – 71 – – 51
Greece 100 100 100 99 99 98 – – – – – – – – – – – – – – – –
Grenada 96 – – 91 – – – – – 100 100 100 – – – 100 100 100 – – – –
Guatemala 94 98 90 65 79 51 77 83 70 – – – 76 76 – – – – – – – –
Guinea 62 86 49 23 34 17 17 26 13 10 10 – – – – – – – – – – –
Guinea-Bissau 67 84 53 21 37 8 6 9 5 – – – – – – – – – – – – 0
Guyana 96 100 94 86 92 84 77 75 78 – – – – – – – – – – – – –
Haiti 65 85 43 35 44 24 23 29 16 – – – – – – – – – – – – 6
Holy See – – – – – – – – – – – – – – – – – – – – – –
Honduras 95 99 89 81 85 76 – – – 59 65 52 82 – – 12 5 21 58 1 – –
Hungary 100 100 100 98 98 99 – – – 100 100 100 92 100 100 99 100 100 – – – –
Iceland 100 100 100 99 99 100 – – – – – – – – – – – – – – – –
India 93 96 91 60 72 53 60 80 49 69 68 75 73 72 79 54 55 53 – – – –
Indonesia 89 95 82 73 80 65 64 72 55 66 65 68 34 31 41 42 43 40 80 – – 66
Iran (Islamic Republic of) 95 97 89 88 92 79 – – – – – – – – – – – – – – – –
Iraq 97 99 91 94 97 88 95 96 90 – – – – – – – – – – – – –
Ireland 97 97 98 91 89 94 – – – – – – – – – – – – – – – –
Israel 100 100 100 100 100 100 – – – 100 100 100 100 100 100 100 100 100 – – – –
Italy 99 99 99 99 99 99 – – – 100 100 100 100 100 100 100 100 100 – – – –
Jamaica 91 96 85 87 86 90 – – – 83 94 69 83 94 69 83 94 69 – – – –
Japan 99 – – 100 – – – – – – – – – – – – – – – – – –
Jordan 99 99 98 97 97 96 – – – 93 – – 33 – – – – – – – – –
Kazakhstan 96 98 92 98 97 99 99 99 99 – – – – – – – – – – – – –
Kenya 59 85 50 29 35 27 25 32 22 – – – – – – – – – 66 – – 33
Kiribati 72 – – 48 – – – – – – – – – – – – – – – – – –
Kuwait 100 – – 100 – – – – – 100 100 100 100 100 100 100 100 100 100 100 100 100
Kyrgyzstan 87 97 82 97 92 99 89 93 87 – – – – – – – – 100 – – – –
Lao People's Democratic Republic 82 94 76 74 95 64 50 67 41 – – – – – – – – – – – – 33
Latvia 99 99 98 92 96 83 – – – 100 100 100 100 100 100 100 100 100 – – – –
Lebanon 93 – – 98 – – – – – 59 60 61 93 92 95 36 34 46 61 16 – 64
Lesotho 69 93 59 43 43 43 2 6 1 – – – – – – – – – – – – –
Liberia 73 84 62 17 28 6 1 2 1 42 – – 43 – – 50 – – – 3 36 67
Libya 99 – – 100 – – – – – – – – 95 – – 13 – – – – – 43
Liechtenstein 100 – – 100 – – – – – – – – – – – – – – – – – –
Lithuania 98 100 93 93 97 85 – – – – – – – – – – – – 100 – – –
Luxembourg 100 100 99 98 97 99 – – – – – – – – – – – – – – – –
Madagascar 54 86 36 11 18 6 – – – – – – – – 52 – – – – – – –
Malawi 69 86 65 26 34 25 9 15 7 – – – 70 72 61 – – – – – – 43
Malaysia 97 99 89 100 100 99 – – – 100 99 100 100 99 100 100 99 100 – – – –
Maldives 99 98 100 99 99 99 96 97 95 – – – – – – – – – 55 15 80 30
Mali 78 92 68 39 53 29 52 70 39 – – – 20 17 20 – – – – – – –
Malta 100 100 100 100 100 100 – – – – – – – – – – – – – – – –
Marshall Islands 88 87 94 83 91 59 83 84 77 3 3 – 27 27 – 36 36 – – – – –
Mauritania 71 89 50 48 75 19 43 55 29 – – – 27 27 26 – – – 81 – – 25
Mauritius 100 100 100 96 96 95 – – – 100 100 100 100 100 100 – – – – – – –
Mexico 99 100 97 91 93 82 88 90 80 – – – 75 75 – – – – – – – –
Micronesia (Federated States of) 79 – – 88 – – – – – – – – – – – – – – – – – –
Monaco 100 100 – 100 100 – – – – 100 100 100 100 100 100 100 100 100 – – – –
Mongolia 83 96 56 58 66 42 71 81 49 74 73 73 63 70 63 41 44 66 – – – –
Montenegro 97 96 99 98 100 94 – – – – – – – – – – – – 100 85 100 100
 242 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 13. WASH

Households Schools Health care facilities

Basic
Basic waste
Basic sanita- Basic man-
At least basic At least basic water tion hygiene agement
drinking water sanitation Basic hygiene Basic water services Basic sanitation services Basic hygiene services services services services services
services (%) services (%) facilities (%) (%) (%) (%) (%) (%) (%) (%)
2017 2017 2017 2016 2016 2016 2016 2016 2016 2016
Countries second- second- second-
and areas total urban rural total urban rural total urban rural total primary ary total primary ary total primary ary total total total total

Montserrat – – – – – – – – – – – – – – – – – – – – – –
Morocco 87 97 71 89 94 79 – – – 82 73 91 70 70 – – – – – – – –
Mozambique 56 84 40 29 52 17 – – – – – – 48 48 – 15 15 – – – – –
Myanmar 82 93 77 64 76 59 79 92 74 71 71 – – – – – – – – – – 3
Namibia 83 96 69 35 51 18 45 62 27 76 – – 46 – – 20 – – – – – –
Nauru 99 99 – 66 66 – – – – – – – 86 100 66 – – – – – – –
Nepal 89 89 89 62 67 61 48 67 43 47 39 76 – – – – – – – – – 1
Netherlands 100 100 100 98 98 100 – – – 100 100 100 100 100 100 100 100 100 – – – –
New Zealand 100 100 100 100 100 100 – – – – – – – – – – – – – – – –
Nicaragua 82 98 59 74 84 62 – – – – – – 43 43 – – – – – – – –
Niger 50 84 44 14 44 8 – – – – – – 21 18 – 14 14 – – – – 60
Nigeria 71 87 56 39 48 31 42 53 31 – – – – – – – – – 50 12 43 43
Niue 98 – – 97 – – – – – 100 100 100 100 100 100 100 100 100 – – – –
North Macedonia 93 91 97 99 100 98 – – – – – – – – – – – – – – – –
Norway 100 100 100 98 98 98 – – – 100 100 100 100 100 100 100 100 100 – – – –
Oman 92 95 78 100 100 100 97 – – 92 – – – – – – – – – – – –
Pakistan 91 94 90 60 77 50 60 83 46 57 52 81 – – – – – – – – – –
Palau 100 100 100 100 100 100 – – – – – – – – – – – – – – – –
Panama 96 98 93 83 92 65 – – – – – – 82 82 – – – – – – – –
Papua New Guinea 41 86 35 13 48 8 – – – 47 46 80 45 44 69 10 10 14 70 – – 10
Paraguay 100 100 99 90 94 83 80 84 72 – – – 77 77 – – – – 85 26 – 6
Peru 91 96 76 74 80 56 – – 56 73 71 73 68 70 72 – – – 46 7 – 28
Philippines 94 98 90 77 78 75 78 85 73 50 49 58 39 33 68 46 49 30 – – – –
Poland 100 100 100 99 99 99 – – – – – – – – – – – – – – – –
Portugal 100 100 100 100 100 100 – – – 100 100 100 100 100 100 100 100 100 – – – –
Qatar 100 – – 100 – – – – – 100 100 100 100 100 100 100 100 100 – – – –
Republic of Korea 100 – – 100 – – – – – 100 100 100 100 100 100 100 100 100 – – – –
Republic of Moldova 89 97 83 76 86 69 – – – 100 100 100 94 100 100 100 100 100 – – – –
Romania 100 100 100 84 95 71 – – – – – – – – – – – – – – – –
Russian Federation 97 99 93 90 95 78 – – – – – – – – – – – – – – – –
Rwanda 58 82 53 67 52 70 5 13 3 44 39 51 88 91 84 48 45 51 – – – –
Saint Kitts and Nevis – – – – – – – – – 84 79 100 – – – 84 79 100 – – – –
Saint Lucia 98 98 98 88 78 91 – – – 99 99 100 99 99 100 99 99 100 – – – –
Saint Vincent and the Grenadines 95 – – 87 – – – – – 100 100 100 100 100 100 100 100 100 – – – –
Samoa 97 100 97 98 98 98 – – – – – 100 – – – – – – – – – –
San Marino 100 – – 100 – – – – – – – – – – – – – – 100 – 100 100
Sao Tome and Principe 84 87 77 43 48 31 41 39 47 – – – 76 73 100 – – – – – – –
Saudi Arabia 100 – – 100 – – – – – – – – – – – – – – – – – –
Senegal 81 92 70 51 65 40 24 42 9 32 32 – – – – 22 25 10 46 – – 31
Serbia 86 83 88 98 100 95 – – – 72 63 91 74 66 92 73 66 91 96 73 100 100
Seychelles 96 – – 100 – – – – – 100 100 100 100 100 100 100 100 100 – – – 80
Sierra Leone 61 76 50 16 26 9 19 27 14 62 – – 12 – – – – – – – – 17
Singapore 100 100 – 100 100 – – – – 100 100 100 100 100 100 100 100 100 – – – –
Slovakia 100 100 100 98 99 97 – – – 100 100 100 100 100 100 100 100 100 – – – –
Slovenia 100 100 99 99 99 99 – – – 100 100 100 100 100 100 100 100 100 – – – –
Solomon Islands 68 91 61 34 78 20 36 59 29 17 20 19 27 22 34 17 – – – – – –
Somalia 52 83 28 38 61 20 10 12 8 – – – – – – – – – – – – 13
South Africa 93 99 81 76 76 75 44 53 27 78 – – – – – – – – – – – –
South Sudan 41 65 35 11 37 5 – – – – – – – – – – – – – – – –
Spain 100 100 100 100 100 100 – – – 100 100 100 100 100 100 100 100 100 – – – –
Sri Lanka 89 97 88 96 95 96 – – – – – – 100 100 100 – – – 99 – – 27
State of Palestine 97 97 96 97 97 96 – – – 80 81 86 81 78 86 23 22 29 – – – –
Sudan 60 74 53 37 60 24 23 32 19 – – – – – – – – – – – – –
Suriname 95 98 90 84 89 75 – – – – – – – – – – – – – – – –
Sweden 100 100 100 99 99 100 – – – – – – – – – – – – – – – –
Switzerland 100 100 100 100 100 100 – – – 100 100 100 100 100 100 100 100 100 – – – –
Syrian Arab Republic 97 99 95 91 91 91 71 72 69 – – – – – – – – – – – – –
Tajikistan 81 96 76 97 95 98 73 87 67 79 – – 44 – – 26 – – – – – –
Thailand 100 100 100 99 99 98 84 85 83 – – – – – – – – – – – – –
Timor-Leste 78 98 70 54 76 44 28 43 22 – – – – – – – – – – – – –
 S TAT I S T I C A L TA B L E S » 2 4 3

TABLE 13. WASH

Households Schools Health care facilities

Basic
Basic waste
Basic sanita- Basic man-
At least basic At least basic water tion hygiene agement
drinking water sanitation Basic hygiene Basic water services Basic sanitation services Basic hygiene services services services services services
services (%) services (%) facilities (%) (%) (%) (%) (%) (%) (%) (%)
2017 2017 2017 2016 2016 2016 2016 2016 2016 2016
Countries second- second- second-
and areas total urban rural total urban rural total urban rural total primary ary total primary ary total primary ary total total total total

Togo 65 89 48 16 29 7 10 20 4 – – – 23 – – – – – 58 – – 30
Tokelau 100 – 100 97 – 97 – – – – – – – – – – – – – – – –
Tonga 100 100 100 93 97 92 – – – – – – – – – – – – – – – –
Trinidad and Tobago 98 – – 93 – – – – – – – – – – – – – – – – – –
Tunisia 96 100 89 91 95 81 79 90 54 70 70 – 99 99 – – – – – – – –
Turkey 99 99 100 97 100 90 – – – – – – – – – – – – – – – –
Turkmenistan 99 100 98 99 98 99 100 100 100 – – – – – – – – – – – – –
Turks and Caicos Islands 94 – – 88 – – – – – – – – – – – – – – – – – –
Tuvalu 99 100 99 84 83 86 – – – – – – – – – – – – – – – –
Uganda 49 75 41 18 26 16 21 34 17 69 – – 79 – – 37 – – 31 12 – 43
Ukraine 94 91 99 96 97 94 – – – – – – – – – 83 69 93 – – – –
United Arab Emirates 98 – – 99 – – – – – – – – – – – – – – – – – –
United Kingdom 100 100 100 99 99 99 – – – – – – – – – – – – – – – –
United Republic of Tanzania 57 86 43 30 43 24 48 63 40 – – – 47 47 – 23 23 – 65 5 35 27
United States 99 100 97 100 100 100 – – – 100 100 100 100 100 100 100 100 100 – – – –
Uruguay 99 100 95 97 97 97 – – – – – – 83 83 – – – – – – – –
Uzbekistan 98 100 96 100 100 100 – – – 90 90 89 92 93 91 89 90 89 – – – –
Vanuatu 91 100 88 34 48 29 25 48 17 – – – – – – – – – – – – –
Venezuela (Bolivarian Republic of) 96 – – 94 – – – – – 97 97 – 90 90 – – – – – – – –
Viet Nam 95 99 93 84 94 78 86 93 82 – – – – – – – – – 51 – – –
Yemen 63 79 55 59 88 43 50 71 38 36 – 46 25 – – 8 – – – – – 13
Zambia 60 84 42 26 36 19 14 26 5 79 76 94 66 – – 54 52 63 40 – – 40
Zimbabwe 64 94 50 36 46 31 37 49 31 64 64 65 – – – – – – 81 17 58 55

SUMMARY
East Asia and Pacific 93 98 86 84 91 75 – – – – 66 – – 43 – – 53 – 87 – 36 –
Europe and Central Asia 98 99 97 97 98 93 – – – 97 99 98 95 99 99 93 97 98 – – – –
Eastern Europe and Central
96 97 94 94 97 88 – – – – – – – – – – – – 98 58 96 –
Asia
Western Europe 100 100 100 99 99 99 – – – 100 100 100 100 100 100 100 100 100 – – – –
Latin America and Caribbean 97 99 88 87 91 69 – – 59 – – – 78 79 – 61 60 65 – – – –
Middle East and North Africa 94 97 88 91 95 82 80 – 70 73 – 80 81 94 99 75 95 94 – – – –
North America 99 100 97 100 100 100 – – – 100 100 100 100 100 100 100 100 100 – – – –
South Asia 92 96 91 59 70 53 57 77 46 68 66 77 71 71 78 53 53 53 – – – –
Sub-Saharan Africa 61 84 46 31 45 22 25 37 17 – – – – – – 21 – – 51 23 – 40
Eastern and Southern Africa 58 85 44 31 49 22 24 38 16 – – – 62 – – 21 18 – 48 33 – 46
West and Central Africa 64 84 48 30 41 21 26 35 19 – – – – – – – – – 55 12 43 36
Least developed countries 65 84 55 34 47 28 28 39 22 57 – – 53 51 62 26 24 38 55 – – 27
World 90 97 81 74 85 59 60 – 46 69 66 75 66 63 72 53 53 55 74 – – –
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES

Population using at least basic drinking water services
– Percentage of the population using an improved drinking
water source, where collection time is not more than 30
minutes for a round trip including queuing (improved sources
include: piped water; boreholes or tubewells; protected dug
wells; protected springs; rainwater; and packaged or delivered
water).
Population using at least basic sanitation services –
Percentage of the population using an improved sanitation
facility that is not shared with other households (improved
facilities include: flush/pour flush to piped sewerage systems,
septic tanks or pit latrines; ventilated improved pit latrines;
composting toilets or pit latrines with slabs).
Population with basic hygiene facilities – Percentage of
the population with a handwashing facility with water and
soap available on premises.
Proportion of schools with basic water services –
Percentage of schools with drinking water from an improved
source available at the time of the survey.
Proportion of schools with basic sanitation services –
Percentage of schools with improved sanitation facilities which
are single-sex and usable.
Proportion of schools with basic hygiene services – Basic water, sanitation and hygiene Basic water, sanitation, hygiene and
Percentage of schools with handwashing facilities with water services in schools – WHO/UNICEF waste management services in
and soap available. Joint Monitoring Programme for Water health care facilities – WHO/UNICEF
Proportion of health care facilities with basic water Supply, Sanitation and Hygiene (JMP). Joint Monitoring Programme for Water
services – Percentage of health care facilities with water Last update: July 2018. Supply, Sanitation and Hygiene (JMP).
available from an improved source located on premises. Basic drinking water, sanitation and Last update: April 2019.
hygiene services in households –
Proportion of health care facilities with basic sanitation
services – Percentage of health care facilities with improved WHO/UNICEF Joint Monitoring
sanitation facilities which are usable with at least one toilet Programme for Water Supply, Sanitation
dedicated for staff, at least one sex-separated toilet with and Hygiene (JMP). Last update: June
menstrual hygiene facilities, and at least one toilet accessible 2019.
for people with limited mobility.
Proportion of health care facilities with basic hygiene NOTES
services – Percentage of health care facilities with functional
– Data not available.
hand hygiene facilities (with water and soap and/or
alcohol-based hand rub) available at points of care, and within
5 metres of toilets.
Proportion of health care facilities with basic waste
management services – Percentage of health care facilities
where waste is safely segregated into at least three bins, and
sharps and infectious waste are treated and disposed of safely.
 244 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 14. ADOLESCENTS

Adolescent
population Education and learning Transition to work
2018 Health Protection 2010–2017* 2010–2018*
Propor-
tion of Intimate Not in
total Alcohol Tobacco Over- partner education, Engagement in
Aged 10–19 popula- use use Thinness weight violence Bullying Proficiency in Proficiency in employment, or household
Countries (thousands) tion (%) 2016 2013–2017* 2016 2016 2010–2018* 2010–2017* math reading training Unemployment chores

and areas total total total total total total female male female male female male female male female male female male female

Afghanistan 9,442 25 0 9 17 9 29 42 45 – – – – 17 59 17 20 9 22
Albania 391 14 38 11 1 24 – – – 39 40 45 51 21 22 27 17 1 2
Algeria 6,242 15 2 9 6 29 – 48 55 18 21 15 28 – – 32 38 1 1
Andorra – – 64 – 1 34 – – – – – – – – – – – – –
Angola 7,290 24 34 – 8 11 24 – – – – – – 5 7 15 12 15 19
Anguilla – – – – – – – 22 30 – – – – – – – – – –
Antigua and Barbuda 14 15 35 12 x 3 25 – 24 x 27 x – – – – – – – – – –
Argentina 7,085 16 55 24 x 1 34 – 25 24 41 35 59 65 13 14 24 32 – –
Armenia 356 12 16 7 x 2 18 – – – 74 79 – – 34 20 – – 0 1
Australia 3,029 12 69 – 1 33 – – – 78 78 77 87 – – 19 15 – –
Austria 876 10 68 – 2 26 – – – 81 75 79 88 10 5 11 12 – –
Azerbaijan 1,311 13 13 7 x 3 18 12 x – – 58 x 51 x 22 x 32 x – – 13 15 – –
Bahamas 65 17 30 13 3 34 – 25 22 – – – – – – 38 46 – –
Bahrain 172 11 4 19 6 34 – 36 23 70 80 – – – – 10 21 – –
Bangladesh 31,080 19 1 9 18 8 28 y 27 17 62 52 87 87 10 30 12 18 – –
Barbados 37 13 38 15 4 26 – 15 11 – – – – – – 44 45 0 0
Belarus 896 9 58 10 2 22 – – – – – – – – – – – 0 0
Belgium 1,285 11 66 – 1 23 – – – 81 79 78 83 4 4 19 20 – –
Belize 78 20 27 12 4 27 – 30 31 – – – – 17 33 13 33 1 3
Benin 2,638 23 15 5 7 11 – 47 52 – – – – 10 20 3 5 18 33
Bhutan 140 19 17 24 15 9 – 31 29 – – – – – – 5 7 2 5
Bolivia (Plurinational State of) 2,280 20 31 19 x 1 27 – 32 28 – – – – 4 8 6 5 – –
Bosnia and Herzegovina 360 11 34 16 2 21 – – – 76 x 77 x – – 16 15 43 51 – –
Botswana 453 20 19 24 x 6 16 – 53 x 52 x 75 84 70 87 24 x 32 x 34 51 – –
Brazil 32,143 15 27 8 y 3 26 – – – 33 26 44 53 16 22 34 44 – –
British Virgin Islands – – – – – – – 18 x 17 x – – – – – – – – – –
Brunei Darussalam 67 16 25 10 6 25 – 25 22 – – – – 15 13 41 48 – –
Bulgaria 654 9 54 29 2 27 – – – 57 59 50 68 12 15 – – – –
Burkina Faso 4,730 24 24 – 8 8 5 – – – – – – – – 5 12 9 29
Burundi 2,526 23 19 19 x 7 10 38 – – – – – – 3 3 3 – 20 30
Cabo Verde 100 18 21 13 x 7 12 – – – – – – – – – 27 47 – –
Cambodia 3,041 19 19 2 11 10 7 23 22 14 18 31 44 9 11 1 1 1 5
Cameroon 5,833 23 26 10 6 12 27 – – – – – – 9 18 3 5 8 22
Canada 3,974 11 52 – 1 31 – – – 86 85 86 92 13 11 17 14 – –
Central African Republic 1,211 26 24 – 8 10 32 x – – – – – – – – – – 14 23
Chad 3,803 25 13 19 x 9 8 15 – – – – – – – – – – 15 30
Chile 2,514 13 54 25 1 34 – 16 14 67 59 69 74 13 15 20 29 8 10
China 166,857 12 41 7 4 25 – – – 84 84 76 81 – – – – – –
Colombia 8,314 17 25 – 2 24 23 – – 80 77 88 90 13 24 16 27 1 3
Comoros 183 22 2 12 7 12 4 – – – – – – 19 x 29 x – – 15 28
Congo 1,176 22 37 24 x 8 11 – – – – – – – 17 x 21 x – – 8 9
Cook Islands – – 36 22 <1 62 6 y 29 32 – – – – – – 26 24 – –
Costa Rica 731 15 24 10 x 2 30 – 18 x 20 x 43 32 56 63 13 15 35 51 0 3
Côte d'Ivoire 5,874 23 25 19 x 6 12 20 y – – – – – – 22 42 – 4 7 18
Croatia 416 10 47 29 x 2 26 – – – 70 66 75 85 16 12 – – – –
Cuba 1,288 11 33 17 x 4 28 – – – – – – – – – 5 y 13 y – –
Cyprus 143 12 55 20 x 1 32 – – – 73 x 82 x 53 75 6 9 – – – –
Czechia 1,002 9 65 21 2 26 – – – 78 79 73 83 2 3 19 – – –
Democratic People's Republic of
3,678 14 27 – 5 22 – – – – – – – – – – – – –
Korea
Democratic Republic of the Congo 19,479 23 24 – 10 10 36 – – – – – – 12 20 8 6 7 20
Denmark 682 12 64 – 1 24 – – – 87 86 82 88 3 2 14 10 – –
Djibouti 180 19 11 15 6 16 – 44 x 36 x – – – – – – – – – –
Dominica – – 31 25 x 3 31 – 29 x 26 x – – – – – – – – – –
Dominican Republic 1,935 18 29 19 x 3 31 22 26 22 10 9 23 33 22 27 10 27 2 4
Ecuador 3,115 18 32 – 1 27 – – – 44 41 70 74 10 19 6 9 – –
Egypt 17,670 18 1 14 3 35 17 70 70 45 49 – – 8 18 16 25 1 5
El Salvador 1,210 19 19 13 2 29 7y 21 24 24 x 17 x – – 14 33 8 y 14 y 7 20
Equatorial Guinea 251 19 59 22 x 8 10 56 p – – – – – – – – – – – –
Eritrea 796 23 12 7 x 8 10 – – – – – – – – – – – – –
Estonia 130 10 62 31 x 2 19 – – – 88 90 86 93 3 5 – – – –
Eswatini 270 24 18 12 x 4 16 – 33 31 – – – – 17 24 37 43 2 3
Ethiopia 26,128 24 13 – 10 8 24 – – – – – – 5 11 2 3 49 58
 S TAT I S T I C A L TA B L E S » 2 4 5

TABLE 14. ADOLESCENTS

Adolescent
population Education and learning Transition to work
2018 Health Protection 2010–2017* 2010–2018*
Propor-
tion of Intimate Not in
total Alcohol Tobacco Over- partner education, Engagement in
Aged 10–19 popula- use use Thinness weight violence Bullying Proficiency in Proficiency in employment, or household
Countries (thousands) tion (%) 2016 2013–2017* 2016 2016 2010–2018* 2010–2017* math reading training Unemployment chores

and areas total total total total total total female male female male female male female male female male female male female

Fiji 154 17 10 12 4 33 – 33 26 – – – – 8 13 16 32 – –
Finland 599 11 62 21 x 1 25 – – – 84 89 84 94 5 6 26 25 – –
France 7,832 12 65 – 1 29 – – – 76 77 74 83 8 6 24 29 – –
Gabon 399 19 52 9 6 15 40 – – – – – – – – 27 38 6 7
Gambia 526 23 16 – 7 11 5 – – – – – – 20 36 6 14 – –
Georgia 457 11 24 12 3 19 – – – 40 46 37 61 – – 25 31 0 0
Germany 7,973 10 70 – 1 25 – – – 85 81 81 86 – – 8 7 – –
Ghana 6,384 21 15 13 x 6 10 23 x – – 25 17 – – 9 18 5 7 3 11
Greece 1,072 10 53 16 x 1 35 – – – 63 65 66 80 10 10 44 59 – –
Grenada 16 14 35 10 4 25 – 29 x 26 x – – – – – – – – – –
Guatemala 3,855 22 17 17 1 27 9 26 20 – – – – 7 40 4 7 – –
Guinea 3,062 25 13 26 x 7 9 – – – – – – – 4 x 5 x – – 11 18
Guinea-Bissau 426 23 17 – 7 10 – – – – – – – – – – – 5 13
Guyana 151 19 26 15 6 24 – 40 37 – – – – 30 40 26 35 2 3
Haiti 2,322 21 22 – 4 26 28 – – – – – – – – 7 10 19 13
Holy See – – – – – – – – – – – – – – – – – – –
Honduras 2,081 22 18 8 2 26 16 13 y 12 y 26 17 – – 13 38 6 10 – –
Hungary 974 10 55 25 2 27 – – – 90 87 68 77 5 6 23 – – –
Iceland 44 13 59 – 1 27 – – – 76 77 71 84 4 – 11 – – –
India 252,611 19 25 15 x 27 6 18 – – 14 x 16 x 11 x 21 x 7 32 12 9 – –
Indonesia 46,369 17 13 13 10 14 – 24 19 30 32 38 51 12 17 20 21 – –
Iran (Islamic Republic of) 11,349 14 2 27 x 9 25 – – – 62 65 – – – – – – – –
Iraq 8,411 22 2 14 5 30 – 32 22 – – – – 17 56 19 7 1 6
Ireland 636 13 71 – <1 29 – – – 94 94 88 92 10 9 21 22 – –
Israel 1,352 16 41 – 1 34 – – – 68 68 68 78 – – 9 9 – –
Italy 5,733 9 51 – 1 34 – – – 90 89 76 82 14 14 46 56 – –
Jamaica 484 16 23 29 x 2 28 11 y 26 25 – – – – – – 41 58 0 0
Japan 11,416 9 46 – 2 13 – – – – – – – – – 4 3 – –
Jordan 2,129 21 2 24 4 30 18 46 x 37 x 41 48 37 70 – – 36 39 0 2
Kazakhstan 2,445 13 26 3 2 19 – – – 90 92 55 63 – – 2 3 – –
Kenya 12,220 24 14 10 8 11 23 57 x 57 x – – – – – – 5 5 – –
Kiribati 23 20 7 29 x <1 54 – 42 32 – – – – – – 27 8 – –
Kuwait 489 12 0 22 4 43 – 36 28 43 46 – – – – – – – –
Kyrgyzstan 1,044 17 15 8 3 15 3 – – 14 13 x 12 x 22 x – – 15 27 2 3
Lao People's Democratic Republic 1,447 20 26 11 9 13 14 y 15 11 – – – – 31 34 18 16 2 2
Latvia 180 9 65 25 2 20 – – – 77 80 76 89 3 2 – – – –
Lebanon 1,182 17 3 60 x 5 31 – 24 12 72 70 28 31 – – 24 x 37 x – –
Lesotho 433 21 10 25 x 6 15 – – – – – – – – – – – – –
Liberia 1,120 23 19 – 7 10 37 x 43 51 – – – – 7 11 – 19 1 5
Libya 1,146 17 0 8 x 6 31 – 40 x 31 x – – – – – – – – – –
Liechtenstein – – – – – – – – – 89 83 85 90 – – – – – –
Lithuania 257 9 71 28 3 19 – – – 73 76 68 82 3 2 – – – –
Luxembourg 66 11 86 – 1 25 – – – 75 73 71 78 3 – – – – –
Madagascar 6,110 23 12 23 x 7 10 – – – – – – – 3 3 3 2 – –
Malawi 4,467 25 14 14 x 6 10 28 43 x 47 x – – – – 17 28 40 50 5 11
Malaysia 5,262 17 18 17 8 25 – 24 18 73 78 54 70 – – – – – –
Maldives 60 12 4 11 14 16 – 30 30 – – – – 20 17 29 16 – –
Mali 4,642 24 13 17 x 8 10 23 x – – – – – – 24 42 – – 13 24
Malta 42 10 49 – 1 35 – – – 83 86 57 72 8 11 – – – –
Marshall Islands – – – 28 <1 58 27 y – – – – – – – – – – – –
Mauritania 956 22 1 22 x 8 13 – 48 46 – – – – 19 42 10 11 10 20
Mauritius 182 14 20 19 7 14 – 29 22 50 x 49 x 45 x 61 x 14 19 29 y 42 y – –
Mexico 22,353 18 29 20 x 2 34 – – – 46 41 54 63 8 21 7 8 2 2
Micronesia (Federated States of) 24 21 9 43 <1 50 35 y – – – – – – 14 19 – 29 y – –
Monaco – – – – <1 <1 – – – – – – – – – 56 y 42 y – –
Mongolia 466 15 20 14 2 17 8 y 36 25 67 x 64 x – – 9 7 14 30 15 19
Montenegro 79 13 41 10 2 24 – – – 48 48 51 66 – – – – 0 1
Montserrat – – – – – – – 32 x 25 x – – – – – – – – – –
Morocco 5,995 17 1 6 6 26 – 44 32 41 41 – – – – 17 11 – –
Mozambique 7,169 24 13 5 4 12 10 y 45 46 – – – – – – 7 5 – –
Myanmar 10,059 19 16 14 13 11 22 51 49 – – – – 11 17 5 5 – –
Namibia 509 21 19 11 8 14 52 p 48 45 – – – – 17 22 37 39 – –
Nauru – – 13 26 x <1 64 – 40 38 – – – – 21 39 – – – –
 246 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 14. ADOLESCENTS

Adolescent
population Education and learning Transition to work
2018 Health Protection 2010–2017* 2010–2018*
Propor-
tion of Intimate Not in
total Alcohol Tobacco Over- partner education, Engagement in
Aged 10–19 popula- use use Thinness weight violence Bullying Proficiency in Proficiency in employment, or household
Countries (thousands) tion (%) 2016 2013–2017* 2016 2016 2010–2018* 2010–2017* math reading training Unemployment chores

and areas total total total total total total female male female male female male female male female male female male female

Nepal 6,305 22 17 7 16 7 17 56 45 – – – – 28 x 26 x 23 26 7 17
Netherlands 1,990 12 61 – 1 24 – – – 83 84 78 86 2 2 9 9 – –
New Zealand 617 13 64 20 x <1 38 – – – 78 78 78 88 – – 21 17 – –
Nicaragua 1,231 19 21 18 2 28 12 y – – – – – – 2 3 6 11 – –
Niger 5,425 24 12 9 x 10 8 – – – – – – – 6 29 – – 17 25
Nigeria 44,938 23 37 – 10 8 9 – – – – – – 21 24 – 11 7 9
Niue – – 21 18 x <1 58 – – – – – – – – – – – – –
North Macedonia 239 11 39 15 2 25 – – – 29 31 22 38 – – 61 63 1 1
Norway 642 12 69 – 1 27 – – – 81 85 79 91 3 2 17 13 – –
Oman 502 10 3 7 7 30 – 45 39 46 59 – – – – 39 51 – –
Pakistan 44,454 21 1 11 19 9 – 45 x 35 x – – – – 7 43 10 6 – –
Palau – – – 45 <1 62 8 y – – – – – – 21 x 18 x – – – –
Panama 715 17 33 13 x 2 28 – – – 21 x 22 x 28 x 41 x 10 15 10 18 – –
Papua New Guinea 1,866 22 7 33 1 31 – – – – – – – 21 21 3 2 – –
Paraguay 1,341 19 23 7 2 27 – 19 15 – – – – 10 23 15 22 4 8
Peru 5,303 17 39 10 1 26 18 47 48 30 26 40 44 17 19 11 9 3 5
Philippines 21,091 20 21 15 10 12 11 53 49 35 x 42 x – – 12 15 5 8 – –
Poland 3,664 10 56 20 x 2 24 – – – 84 82 81 91 3 2 – – – –
Portugal 1,042 10 58 17 1 30 – – – 77 76 80 86 5 4 31 36 – –
Qatar 229 8 26 16 5 37 – 49 35 62 66 39 58 – – 0 1 – –
Republic of Korea 5,056 10 51 6 2 25 – – – 82 87 81 92 – – 11 7 – –
Republic of Moldova 420 10 53 10 3 17 15 x – – 49 50 43 65 – – – – – –
Romania 2,064 11 55 11 3 23 – – – 60 60 58 64 11 12 27 – – –
Russian Federation 14,358 10 40 15 2 19 – – – 82 81 79 88 – – 28 31 – –
Rwanda 2,769 23 23 12 x 6 11 – – – – – – – 21 27 18 19 22 31
Saint Kitts and Nevis – – 40 9 x 4 27 – 25 20 – – – – – – – – – –
Saint Lucia 26 14 35 21 x 4 22 – 25 x 25 x – – – – – – – – 3 1
Saint Vincent and the Grenadines 18 16 32 19 x 4 28 – 31 x 29 x – – – – – – – – – –
Samoa 41 21 9 41 x <1 51 – 79 69 – – – – 27 21 34 64 – –
San Marino – – – 15 <1 <1 – – – – – – – – – 34 45 – –
Sao Tome and Principe 51 24 21 26 x 6 13 28 x – – – – – – – – – – 12 15
Saudi Arabia 4,792 14 3 15 x 8 35 – – – 31 37 – – – – 37 65 – –
Senegal 3,629 23 12 11 10 9 19 – – – – – – 27 36 6 6 6 23
Serbia 1,019 12 47 10 x 2 26 – – – 63 60 57 77 12 11 43 48 0 0
Seychelles 13 14 39 21 6 21 – 45 50 – – – – – – 20 22 – –
Sierra Leone 1,788 23 19 – 7 10 31 60 57 – – – – 7 9 13 7 4 5
Singapore 548 10 57 9 x 2 21 – – – 99 99 86 92 – – 4 15 – –
Slovakia 541 10 57 29 x 1 22 – – – 72 72 61 75 7 6 37 36 – –
Slovenia 190 9 60 21 x 1 25 – – – 84 84 79 91 4 3 – – – –
Solomon Islands 142 22 7 40 x 1 24 – 64 68 – – – – 2 2 – – 6 9
Somalia 3,739 25 0 – 7 12 – – – – – – – – – – – – –
South Africa 10,080 17 20 22 x 4 26 – – – 33 36 – – 13 15 61 69 1 2
South Sudan 2,536 23 – – <1 <1 – – – – – – – – – – – – –
Spain 4,614 10 57 – 1 32 – – – 80 76 80 87 11 10 50 50 – –
Sri Lanka 3,347 16 18 8 15 12 – 50 29 63 71 – – 15 17 23 34 – –
State of Palestine 1,072 22 – – – – – – – 47 57 – – 20 18 42 61 1 6
Sudan 9,724 23 1 12 <1 <1 – – – – – – – – – 29 33 4 7
Suriname 102 18 28 12 4 30 – 25 25 – – – – – – – – 2 2
Sweden 1,080 11 62 – 2 23 – – – 82 82 76 88 3 3 30 25 – –
Switzerland 836 10 72 – <1 21 – – – 84 84 76 85 5 5 9 9 – –
Syrian Arab Republic 3,320 20 1 21 x 6 27 – – – 45 41 – – – – 14 x 48 x – –
Tajikistan 1,708 19 12 4 4 14 6 7 x 7 x – – – – 20 x 38 x 15 x 4 x – –
Thailand 8,775 13 27 14 8 20 – 38 28 45 47 41 57 9 11 4 5 – –
Timor-Leste 304 24 13 23 11 11 38 39 25 – – – – 14 13 – 14 – –
Togo 1,815 23 15 8 7 10 13 – – – – – – 5 10 – – 9 16
Tokelau – – – – – – – 39 39 – – – – – – – – – –
Tonga 23 22 8 19 <1 57 41 x,y 46 31 – – – – – – – – – –
Trinidad and Tobago 181 13 44 12 x 6 23 – 13 18 43 52 48 67 – – 7 – 0 0
Tunisia 1,604 14 3 11 x 7 24 – 37 x 24 x 27 24 23 33 15 20 32 28 1 1
Turkey 13,559 16 4 17 x 5 28 18 y – – 69 71 54 66 14 25 16 20 – –
Turkmenistan 969 17 18 0 3 17 – – – – – – – – – – – 0 0
Turks and Caicos Islands – – – – – – – – – – – – – – – – – – –
Tuvalu – – 8 21 <1 57 – 40 15 – – – – 15 23 – – – –
 S TAT I S T I C A L TA B L E S » 2 4 7

TABLE 14. ADOLESCENTS

Adolescent
population Education and learning Transition to work
2018 Health Protection 2010–2017* 2010–2018*
Propor-
tion of Intimate Not in
total Alcohol Tobacco Over- partner education, Engagement in
Aged 10–19 popula- use use Thinness weight violence Bullying Proficiency in Proficiency in employment, or household
Countries (thousands) tion (%) 2016 2013–2017* 2016 2016 2010–2018* 2010–2017* math reading training Unemployment chores

and areas total total total total total total female male female male female male female male female male female male female

Uganda 10,668 25 24 17 x 6 10 31 50 x 41 x – – – – 8 13 4 3 7 18
Ukraine 4,188 9 45 19 x 2 20 2 x – – 80 82 – – – – – – 2 2
United Arab Emirates 816 8 8 12 5 34 – 33 22 70 78 48 70 8 9 27 23 – –
United Kingdom 7,500 11 62 – 1 30 – – – 79 77 79 85 8 8 19 17 – –
United Republic of Tanzania 13,169 23 24 6 7 11 30 25 y 28 y – – – – 10 16 3 4 4 7
United States 42,365 13 60 13 1 41 – 26 y 25 y 71 70 77 85 12 11 15 y 11 y – –
Uruguay 488 14 57 13 2 32 – 18 20 50 45 55 66 14 16 33 44 1 2
Uzbekistan 5,309 16 12 14 3 16 – – – – – – – – – – – – –
Vanuatu 62 21 7 26 x 2 29 – 60 46 – – – – – – 10 x 11 x 1 0
Venezuela (Bolivarian Republic of) 5,171 18 25 9 x 2 33 – – – 46 x 36 x 55 x 61 x 12 21 13 18 – –
Viet Nam 13,324 14 23 4 14 9 16 y 26 26 79 83 81 91 8 9 8 7 2 4
Yemen 6,511 23 0 16 14 18 – 47 33 – – – – 18 58 – – – –
Zambia 4,298 25 17 26 x 6 12 30 63 x 67 x – – – – 26 34 28 21 8 9
Zimbabwe 3,366 23 10 20 6 14 32 – – – – – – 8 17 9 18 – –

SUMMARY
East Asia and Pacific 303,742 13 35 9 6 21 – – – 72 71 67 73 – – – – – –
Europe and Central Asia 103,867 11 47 – 2 25 – – – 78 78 72 81 10 12 19 19 – –
Eastern Europe and Central
52,241 12 30 12 3 21 – – – 72 75 64 75 – – 19 23 – –
Asia
Western Europe 51,625 10 62 – 1 28 – – – 82 80 78 85 8 7 19 18 – –
Latin America and Caribbean 106,649 17 30 – 2 29 – – – 42 37 54 61 13 22 18 27 – –
Middle East and North Africa 74,983 17 3 13 6 29 – 52 46 45 48 – – – – 21 21 1 4
North America 46,339 13 59 13 1 40 – 26 25 86 71 86 85 12 11 15 12 – –
South Asia 347,439 19 19 – 24 7 19 – – – – – – 8 33 12 13 – –
Sub-Saharan Africa 249,533 23 21 – 8 10 22 – – – – – – 13 20 8 9 13 20
Eastern and Southern Africa 129,278 23 16 – 7 11 26 – – – – – – 9 14 8 9 19 25
West and Central Africa 120,255 23 26 – 9 9 18 – – – – – – 17 25 – 8 8 16
Least developed countries 228,364 23 13 – 10 9 26 – – – – – – 11 23 9 10 15 24
World 1,232,553 16 30 – 11 17 – – – – – – – 10 24 13 14 – –
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES

Alcohol use – Percentage of adolescents ages 15−19 who
had at least one alcoholic drink at any time during the last
twelve months.
Tobacco use – Percentage of adolescents ages 13−15 who
smoked cigarettes or used smoked or smokeless tobacco
products at any time during the last one month.
Thinness – Percentage of adolescents aged 10–19 years with
BMI < −2 SD of the median according to the WHO growth
reference for school-age children and adolescents.
Overweight – Percentage of adolescents aged 10–19 years
with BMI > 1 SD of the median according to the WHO growth
reference for school-age children and adolescents.
Intimate partner violence – Percentage of ever-partnered
girls aged 15–19 years who have experienced physical and/or
sexual violence by a current or former intimate partner during
the last twelve months.
Bullying – Percentage of students aged 13–15 years who
reported being bullied on one or more days in the past 30 days.
Proficiency in math – Percentage of children and young
people at the end of lower secondary achieving at least a
minimum proficiency level in math.
Proficiency in reading – Percentage of children and young
people at the end of lower secondary achieving at least a
minimum proficiency level in reading.
Not in education, employment or training (NEET) –
Percentage of adolescents aged 15–19 years not in education,
employment or training.
Unemployment – Percentage of adolescents aged 15–19
years in the labour force who are unemployed.
Engagement in household chores – Percentage of
adolescents aged 10–14 years who, during the reference week,
spent at least 21 hours on unpaid household services.
Alcohol use – WHO estimates based on
international surveys (WHS, STEPS,
GENACIS, and ECAS) as well as national
surveys. Last update: August 2019.
Tobacco use – School-based surveys,
other national surveys, and censuses. Last
update: August 2019.
Intimate partner violence – DHS, MICS
and other national surveys. Last update:
March 2019.
Thinness and overweight – NCD Risk
Factor Collaboration (NCD−RisC), based on
Worldwide trends in body mass index,
underweight, overweight and obesity from
1975 to 2016: a pooled analysis of 2416
population-based measurement studies in
128.9million children, adolescents, and
adults. The Lancet 2017, 390 (10113):
2627–2642. Last update: August 2019.
Intimate partner violence – DHS, MICS
and other national surveys. Last update:
March 2019.
Bullying – Health Behaviour in
School-aged Children Study (HBSC) and
Global School-based Student Health
Surveys (GSHS). Last update: August 2019.
Proficiency in math and reading –
United Nations Statistics Division. Last
update: April 2019.
NEET – International Labour Organization.
Last update: February 2019.
Unemployment – International Labour
Organization. Last update: August 2019.
Engagement in household chores –
DHS, MICS and other national surveys.
Last update: March 2019.

NOTES
– Data not available.
p Based on small denominators
(typically 25-49 unweighted cases).
No data based on fewer than 25
unweighted cases are displayed.
x Data refer to years or periods other
than those specified in the column
heading. Such data are not included
in the claculation of regional and
global averages. Data from years
prior to 2000 are not displayed.
y Data differ from the standard defini-
tion or refer to only part of a country.
If they fall within the noted reference
period, such data are included in the
calculation of regional and global
averages.
* Data refer to the most recent year
available during the period specified
in the column heading.
 248 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 15. ECONOMIC INDICATORS

Government Expenditure
2010–2018*

Government As % of GDP As % of government budget Official Development Assistance 2010–2018*

Countries revenue as % of
GDP On On social On social Inflow in Inflow as a % Outflow in Ouflow as a %
and areas 2010–2018* Total On health education protection On health On education protection millions US$ of recipient GNI millions US$ of donor GNI

Afghanistan 12.2 36.7 0.5 3.2 − 2.0 12.5 − 3804.0 18.1 − −

Albania 25.7 23.9 2.9 3.4 1.6 9.5 11.3 0.1 157.0 1.2 − −
Algeria 40.4 29.5 4.9 − − 10.7 − − 189.0 0.1 − −
Andorra − − 5.0 3.3 − 15.2 − − − − − −
Angola 16.4 16.7 1.4 3.5 2.3 4.6 8.7 0.1 223.0 0.2 − −
Anguilla − − − − − − − − − − − −
Antigua and Barbuda 19.3 − 3.2 − − 12.3 − − 10.0 0.7 − −
Argentina 19.5 24.3 6.8 5.8 2.1 16.6 14.0 0.1 −5.0 0.0 − −
Armenia 22.5 22.6 1.6 2.8 1.4 6.1 10.7 0.1 255.0 2.1 − −
Australia 24.8 26.6 6.4 5.3 − 17.2 14.1 − − − 3036.0 0.2
Austria 43.5 44.2 7.5 5.5 − 14.8 10.7 − − − 1251.0 0.3
Azerbaijan 35.2 28.0 1.4 3.0 0.8 3.7 7.6 0.0 116.0 0.3 − −
Bahamas 16.9 19.1 3.0 − − 15.9 − − − − − −
Bahrain 24.0 23.4 3.2 2.7 − 8.8 7.3 − − − − −
Bangladesh 10.2 9.4 0.4 1.5 0.7 3.4 11.4 0.1 3740.0 1.4 − −
Barbados 27.5 36.3 3.2 4.7 − 9.1 12.9 − − − − −
Belarus 29.6 29.3 3.7 4.8 3.1 8.5 11.5 0.1 −253.0 −0.5 − −
Belgium 39.0 40.2 8.4 6.6 − 15.7 12.2 − − − 2196.0 0.5
Belize 29.0 27.2 4.1 6.7 − 11.4 21.2 − 34.0 2.0 − −
Benin 16.7 − 0.8 4.4 3.0 3.2 17.5 − 676.0 7.3 − −
Bhutan − 17.9 2.7 7.4 0.3 10.0 26.4 0.0 119.0 5.1 − −
Bolivia (Plurinational State of) − − 4.4 7.3 2.2 9.8 16.8 − 947.0 2.6 − −
Bosnia and Herzegovina 38.8 34.4 6.6 − 3.9 15.2 − 0.1 441.0 2.4 − −
Botswana 31.1 26.1 3.3 − 1.7 8.8 − 0.1 102.0 0.6 − −
Brazil 27.2 34.9 3.8 6.2 1.4 9.9 16.2 0.0 265.0 0.0 − −
British Virgin Islands − − − 6.3 − − − − − − − −
Brunei Darussalam − − 2.3 4.4 − 5.9 11.4 − − − − −
Bulgaria 32.4 32.3 4.2 − 1.4 10.3 11.4 0.0 − − − −
Burkina Faso 19.2 21.1 1.7 4.2 2.0 7.2 18.0 0.1 885.0 7.1 − −
Burundi 14.5 17.0 2.5 6.4 2.3 9.1 24.2 0.1 428.0 12.3 − −
Cabo Verde − 28.4 3.6 5.3 2.5 11.4 16.7 0.1 123.0 7.3 − −
Cambodia 18.6 14.3 1.3 1.9 0.9 6.6 8.8 0.1 843.0 4.1 − −
Cameroon − 10.9 0.7 2.8 0.0 3.3 13.2 0.0 1213.0 3.5 − −
Canada 17.8 17.3 7.6 5.3 − 19.2 12.2 − − − 4305.0 0.3
Central African Republic − 7.8 0.6 1.2 2.8 4.3 7.8 0.4 508.0 26.0 − −
Chad − − 1.1 2.9 0.7 5.8 12.5 − 648.0 6.6 − −
Chile 21.1 22.4 4.9 4.9 3.5 19.6 19.6 0.2 69.0 0.0 − −
China 15.7 8.6 2.9 − 0.8 9.4 − 0.1 −1045 0.0 − −
Colombia 22.7 25.3 3.8 4.5 3.0 12.8 15.1 0.1 845.0 0.3 − −
Comoros − − 1.0 4.3 0.7 3.8 15.3 − 67.0 10.2 − −
Congo 43.8 20.1 1.6 4.6 0.1 2.9 8.0 0.0 108.0 1.4 − −
Cook Islands − − − − − − − − 19.0 − − −
Costa Rica 24.4 26.4 5.8 7.1 0.7 29.9 − 0.0 99.0 0.2 − −
Côte d'Ivoire 16.5 20.6 1.1 4.8 − 5.0 21.2 − 827.5 2.1 − −
Croatia 39.8 38.6 5.6 4.6 3.4 11.7 9.5 0.1 − − − −
Cuba − − 11.5 12.8 − 18.2 − − 718.0 − − −
Cyprus 38.3 36.1 2.9 6.4 − 7.1 16.3 − − − − −
Czechia 31.8 32.1 6.0 5.8 − 14.3 13.9 − − − 304.0 0.2
Democratic People's Republic of
− − − − − − − − 133.0 − − −
Korea
Democratic Republic of the Congo 14.3 8.4 0.7 2.2 0.7 4.0 11.7 0.1 2280.0 6.3 − −
Denmark 38.9 37.5 8.6 7.6 − 15.8 13.8 − − − 2448.0 0.7
Djibouti − − 2.4 4.5 0.2 4.1 12.3 − 134.0 7.3 − −
Dominica 26.3 − 3.6 3.4 − 10.6 10.5 − 19.0 3.5 − −
Dominican Republic 16.0 16.9 2.5 − 1.2 14.0 − 0.1 118.0 0.2 − −
Ecuador − − 4.2 5.0 1.5 10.8 12.6 − 203.0 0.2 − −
Egypt 21.0 30.2 1.6 − 0.2 5.0 − 0.0 −114.0 −0.1 − −
El Salvador 25.3 24.9 4.4 4.0 0.8 20.8 16.6 0.0 152.0 0.7 − −
Equatorial Guinea 17.2 9.8 0.6 − − 1.4 − − 7.0 0.1 − −
Eritrea − − 0.4 − − 1.2 − − 79.0 − − −
Estonia 35.0 35.2 4.9 5.2 2.6 12.1 13.0 0.1 − − − −
Eswatini 29.2 − 5.0 7.1 1.7 14.9 24.9 − 147.0 3.3 − −
Ethiopia 9.6 11.2 1.0 4.7 1.0 5.9 27.1 0.1 4117.0 5.1 − −
Fiji 28.7 26.5 2.3 3.9 1.1 7.0 14.3 0.0 146.0 3.0 − −
 S TAT I S T I C A L TA B L E S » 2 4 9

TABLE 15. ECONOMIC INDICATORS

Government Expenditure
2010–2018*

Government As % of GDP As % of government budget Official Development Assistance 2010–2018*

Countries revenue as % of
GDP On On social On social Inflow in Inflow as a % Outflow in Ouflow as a %
and areas 2010–2018* Total On health education protection On health On education protection millions US$ of recipient GNI millions US$ of donor GNI

Finland 36.9 38.2 7.6 7.1 − 13.3 12.4 − − − 1084.0 0.4

France 44.8 47.5 8.8 5.5 − 15.5 9.6 − − − 11331.0 0.4
Gabon − 17.1 1.6 2.7 0.2 7.0 11.2 0.0 106.0 0.8 − −
Gambia − − 0.8 3.1 − 2.8 10.4 − 270.0 27.3 − −
Georgia 25.0 24.8 2.8 3.8 7.0 9.6 13.0 0.3 446.0 3.1 − −
Germany 28.3 27.9 9.3 4.8 − 21.3 11.0 − − − 25005.0 0.7
Ghana 17.5 30.5 2.1 5.9 0.6 8.6 23.8 0.0 1257.0 2.8 − −
Greece 46.7 47.4 4.7 − − 8.8 − − − − 314.0 0.2
Grenada 20.4 20.0 1.9 10.3 2.0 7.4 42.8 0.1 6.0 0.5 − −
Guatemala 11.0 11.8 1.9 3.0 0.2 15.7 24.1 0.0 367.0 0.5 − −
Guinea − − 0.4 2.5 1.6 2.0 11.6 − 457.0 4.4 − −
Guinea-Bissau − 12.6 2.2 2.1 0.0 9.4 16.2 0.0 113.0 8.4 − −
Guyana − − 2.3 5.3 − 7.8 17.8 − 51.0 1.4 − −
Haiti − − 0.9 3.2 − 4.0 14.4 − 980.0 11.6 − −
Holy See − − − − − − − − − − − −
Honduras 23.4 22.0 3.0 6.4 0.8 11.4 24.6 0.0 441.0 2.1 − −
Hungary 39.9 42.1 4.7 4.6 3.1 9.4 9.1 0.1 − − 149.0 0.1
Iceland 32.2 29.9 6.7 7.7 − 15.9 18.2 − − − 68.0 0.3
India − 14.9 0.9 3.8 1.5 3.1 14.1 0.1 3094.0 0.1 − −
Indonesia 12.2 14.3 1.2 3.6 0.8 6.9 20.5 0.1 234.0 0.0 − −
Iran (Islamic Republic of) − − 4.0 2.8 − 22.6 18.6 − 140.0 0.0 − −
Iraq 26.9 26.0 0.7 − 2.6 1.7 − 0.1 2907.0 1.5 − −
Ireland 24.8 24.4 5.3 3.8 − 18.4 13.0 − − − 838.0 0.3
Israel 33.6 36.7 4.6 5.9 − 11.6 15.0 − − − − −
Italy 38.0 41.5 6.7 4.1 − 13.3 8.1 − − − 5858.0 0.3
Jamaica 29.3 26.6 3.6 5.5 − 12.9 20.1 − 59.0 0.4 − −
Japan 12.8 16.4 9.1 3.5 − 23.2 9.1 − − − 11463.0 0.2
Jordan 30.0 26.1 3.6 3.6 0.7 12.0 12.5 0.0 2921.0 7.3 − −
Kazakhstan 16.6 19.5 1.9 2.8 1.6 8.4 12.2 0.1 59.0 0.0 − −
Kenya 21.9 26.2 1.7 5.3 0.4 6.3 16.7 0.0 2475.0 3.3 − −
Kiribati 100.5 77.4 6.9 − 0.7 6.3 − 0.0 77.0 22.2 − −
Kuwait 38.6 52.0 3.4 − 0.8 6.2 − 0.0 − − − −
Kyrgyzstan 28.5 26.0 2.7 6.0 3.1 7.3 15.8 0.1 461.0 6.3 − −
Lao People's Democratic Republic 14.5 − 0.9 2.9 0.2 3.8 − − 476.0 3.0 − −
Latvia 41.0 42.6 3.3 5.3 0.8 8.5 14.1 0.0 − − − −
Lebanon 19.8 25.8 3.9 2.5 1.0 14.3 8.6 0.0 1306.0 2.5 − −
Lesotho 33.8 35.2 5.4 − 7.1 11.3 13.8 0.2 147.0 5.0 − −
Liberia − 16.5 1.1 4.1 2.6 3.1 7.2 0.2 622.0 33.5 − −
Libya − − − − − 0.0 − − 432.0 0.8 − −
Liechtenstein − − − 2.6 − − − − − − − −
Lithuania 31.2 31.2 4.3 4.2 0.5 12.3 12.3 0.0 − − − −
Luxembourg 42.0 39.8 5.1 3.9 − 12.2 9.4 − − − 424.0 1.0
Madagascar − − 2.4 − 0.2 15.6 19.0 − 780.0 7.0 − −
Malawi 18.5 18.8 2.7 5.6 1.5 9.7 21.6 0.1 1515.0 24.6 − −
Malaysia 16.3 16.0 2.1 5.0 0.7 8.2 19.8 0.0 −29 0.0 − −
Maldives 25.7 25.1 6.4 4.5 1.2 18.2 12.9 0.0 42.0 1.0 − −
Mali 17.4 12.5 1.0 3.8 0.6 4.7 18.2 0.0 1356.0 9.1 − −
Malta 39.5 34.9 5.7 5.3 − 14.2 13.2 − − − − −
Marshall Islands 39.3 63.2 11.6 − 1.1 20.2 − 0.0 72.0 27.4 − −
Mauritania − − 1.8 2.6 2.5 5.5 9.3 − 284.0 5.7 − −
Mauritius 22.3 23.0 2.4 4.9 3.5 9.5 19.5 0.2 12.0 0.1 − −
Mexico 20.1 20.4 3.0 5.2 1.7 10.9 19.0 0.1 737.0 0.1 − −
Micronesia (Federated States of) 34.2 24.2 3.2 12.5 − 5.8 22.3 − 98.0 25.1 − −
Monaco − − 1.6 − − 8.1 − − − − − −
Mongolia 21.1 23.8 2.0 4.2 2.0 6.0 12.4 0.1 764.0 7.7 − −
Montenegro − − − − 1.8 − − − 117.0 2.4 − −
Montserrat − − − − − − − − 36.0 − − −
Morocco 32.7 24.5 2.4 − 1.1 7.7 − 0.0 1885.0 1.8 − −
Mozambique 25.1 18.4 0.4 6.5 1.3 1.2 19.0 0.1 1776.0 14.9 − −
Myanmar 15.8 16.8 1.1 2.2 0.3 4.9 9.4 0.0 1543.0 2.3 − −
Namibia 34.2 34.8 5.3 3.1 3.2 12.4 7.6 0.1 187.0 1.4 − −
Nauru − 85.0 5.3 − − 5.0 − − 26.0 17.8 − −
Nepal 23.2 19.6 1.0 3.7 1.3 5.1 17.0 0.1 1258.0 5.1 − −
 250 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 15. ECONOMIC INDICATORS

Government Expenditure
2010–2018*

Government As % of GDP As % of government budget Official Development Assistance 2010–2018*

Countries revenue as % of
GDP On On social On social Inflow in Inflow as a % Outflow in Ouflow as a %
and areas 2010–2018* Total On health education protection On health On education protection millions US$ of recipient GNI millions US$ of donor GNI

Netherlands 39.2 37.8 8.4 5.4 − 18.8 12.3 − − − 4958.0 0.6

New Zealand 32.6 30.5 7.4 6.3 − 22.1 16.4 − − − 450.0 0.2
Nicaragua 17.8 16.4 4.5 4.1 2.2 17.9 − 0.1 563.0 4.2 − −
Niger − − 1.5 6.0 0.7 4.6 18.5 − 1207.0 15.2 − −
Nigeria 5.0 − 0.6 − 0.3 5.3 − − 3359.0 0.9 − −
Niue − − − − − − − − 15.0 − − −
North Macedonia 26.5 28.1 4.1 − − 12.8 − − − − − −
Norway 45.4 38.8 8.6 7.6 − 17.7 15.7 − − − 4125.0 1.0
Oman 49.5 34.6 3.8 6.7 − 7.6 15.3 − − − − −
Pakistan − 17.6 0.7 2.7 0.6 3.7 13.2 0.0 2283.0 0.7 − −
Palau 26.6 41.7 4.5 − − 13.3 − − 22.0 7.9 − −
Panama − − 4.2 3.2 1.5 11.6 13.0 − 41.0 0.1 − −
Papua New Guinea 15.4 16.9 1.7 − 0.0 8.2 − 0.0 532.0 2.6 − −
Paraguay 17.3 15.6 4.2 4.5 − 10.9 − − 143.0 0.5 − −
Peru 17.0 20.3 3.2 4.0 1.4 14.5 17.6 0.1 −8.0 0.0 − −
Philippines 15.6 14.3 1.4 − 0.7 7.3 − 0.0 160.0 0.0 − −
Poland 33.6 34.2 4.4 4.8 2.0 10.7 11.6 0.1 − − 679.0 0.1
Portugal 37.8 41.7 5.9 4.9 − 12.3 10.2 − − − 381.0 0.2
Qatar 34.2 18.7 2.6 2.9 − 6.3 8.9 − − − − −
Republic of Korea 27.8 25.4 4.2 5.3 − 12.9 − − − − 2201.0 0.1
Republic of Moldova 32.2 26.8 4.6 − 1.3 12.2 18.3 0.0 241.0 2.8 − −
Romania 28.6 31.6 3.9 3.1 1.1 10.8 9.1 0.0 − − − −
Russian Federation 24.4 30.6 3.1 3.8 1.9 8.8 10.9 0.1 − − − −
Rwanda 20.0 18.9 2.2 3.8 1.5 7.9 12.5 0.1 1225.0 13.7 − −
Saint Kitts and Nevis 28.0 24.4 2.1 2.8 − 6.6 8.6 − − − − −
Saint Lucia 22.3 19.4 2.2 4.4 0.5 8.6 16.5 0.0 13.0 0.8 − −
Saint Vincent and the Grenadines 27.5 26.6 2.6 5.8 − 9.2 19.0 − 7.0 0.9 − −
Samoa 27.0 22.9 4.5 4.1 0.8 11.5 10.5 0.0 130.0 15.6 − −
San Marino 39.8 42.2 5.5 2.4 − 13.3 10.6 − − − − −
Sao Tome and Principe 16.0 18.2 1.7 3.9 − 4.9 11.3 − 40.0 10.2 − −
Saudi Arabia − 28.0 4.1 − 0.7 10.1 − 0.0 − − − −
Senegal 17.2 18.0 1.7 7.1 1.0 5.8 23.8 0.1 910.0 5.8 − −
Serbia 34.9 36.9 5.4 4.0 2.0 12.3 8.9 0.1 1688.0 4.4 − −
Seychelles 36.4 33.3 3.2 4.4 2.6 10.0 11.7 0.1 19.0 1.4 − −
Sierra Leone 9.8 11.8 1.6 4.6 0.9 7.9 19.9 0.1 538.0 14.7 − −
Singapore 21.4 14.5 2.2 2.9 − 12.4 20.0 − − − − −
Slovakia 37.5 38.9 5.4 4.6 2.4 12.0 10.3 0.1 − − 119.0 0.1
Slovenia 37.9 38.0 6.1 4.9 2.6 12.7 11.2 0.1 − − 76.0 0.2
Solomon Islands 32.7 33.6 3.5 9.9 − 7.3 17.5 − 187.0 15.3 − −
Somalia − 0.0 − − 0.2 − − 1422.8 1760.0 24.0 − −
South Africa 30.9 34.4 4.4 6.0 3.3 13.3 18.7 0.1 1014.0 0.3 − −
South Sudan − − − 1.4 10.1 − 3.3 − 2183.0 − − −
Spain 15.6 18.7 6.5 4.3 − 14.9 9.8 − − − 2560.0 0.2
Sri Lanka 13.8 16.4 1.7 2.2 0.7 8.4 11.0 0.0 297.0 0.4 − −
State of Palestine 6.9 8.3 − 5.1 2.3 − − 0.3 2111.0 12.8 − −
Sudan − 10.5 2.1 − 1.0 18.1 − 0.1 840.0 0.8 − −
Suriname 25.7 22.4 4.0 − − 12.7 − − 20.0 0.6 − −
Sweden 33.1 31.3 9.2 7.6 − 18.5 15.5 − − − 5563.0 1.0
Switzerland 18.4 17.4 7.5 5.1 − 22.1 15.5 − − − 3138.0 0.5
Syrian Arab Republic − − − − − 0.0 − − 10361.0 − − −
Tajikistan − − 1.9 5.2 0.6 6.1 16.4 − 304.0 3.7 − −
Thailand 19.2 18.4 2.8 4.1 0.5 15.3 19.1 0.0 250.0 0.1 − −
Timor-Leste 32.4 36.4 2.3 2.7 6.5 4.5 6.8 0.2 232.0 8.9 − −
Togo 18.8 15.4 1.3 5.2 0.2 4.2 16.7 0.0 345.0 6.9 − −
Tokelau − − − − − − − − 7.0 − − −
Tonga − 31.4 2.7 − − 6.8 − − 80.0 18.6 − −
Trinidad and Tobago 39.4 35.8 3.2 − − 8.3 − − − − − −
Tunisia 31.4 35.5 4.0 6.6 0.8 13.9 22.9 0.0 776.0 2.0 − −
Turkey 29.7 31.9 3.2 4.3 1.1 9.7 12.8 0.0 3142.0 0.4 − −
Turkmenistan − − 1.5 3.0 − 8.7 20.8 − 29.0 0.1 − −
Turks and Caicos Islands − − − 3.3 − − − − − − − −
Tuvalu − − 13.2 − − 10.3 − − 27.0 45.3 − −
Uganda 14.6 13.3 1.0 2.8 0.8 5.1 12.1 0.1 2008.0 7.9 − −
 S TAT I S T I C A L TA B L E S » 2 5 1

TABLE 15. ECONOMIC INDICATORS

Government Expenditure
2010–2018*

Government As % of GDP As % of government budget Official Development Assistance 2010–2018*

Countries revenue as % of
GDP On On social On social Inflow in Inflow as a % Outflow in Ouflow as a %
and areas 2010–2018* Total On health education protection On health On education protection millions US$ of recipient GNI millions US$ of donor GNI

Ukraine 32.6 33.6 2.9 5.0 4.4 6.6 12.4 0.1 1166.0 1.0 − −
United Arab Emirates 3.5 4.1 2.6 − − 7.9 − − − − − −
United Kingdom 35.7 36.4 7.9 5.6 − 18.5 13.8 − − − 18103.0 0.7
United Republic of Tanzania 16.4 15.7 1.3 3.5 0.5 7.3 17.3 0.0 2584.0 5.0 − −
United States 19.7 22.4 13.8 5.0 − 36.6 13.6 − − − 34732.0 0.2
Uruguay 32.6 34.1 6.2 4.4 1.2 19.0 14.9 0.0 41.0 0.1 − −
Uzbekistan 21.8 15.0 3.0 7.1 − 9.0 21.1 − 638.0 1.3 − −
Vanuatu 25.0 27.9 2.0 5.5 0.3 4.9 13.0 0.0 132.0 15.5 − −
Venezuela (Bolivarian Republic of) − − 2.0 − − 4.1 − − 87.0 − − −
Viet Nam 21.5 21.6 2.4 5.7 1.0 7.9 18.5 0.0 2376.0 1.1 − −
Yemen − − 0.6 − − 2.2 − − 3234.0 − − −
Zambia 16.9 20.8 2.1 − 0.3 7.4 − 0.0 1023.0 4.1 − −
Zimbabwe 17.4 26.6 4.0 7.5 0.4 15.9 30.0 0.0 726.0 4.6 − −

SUMMARY
** ** ** **
East Asia and Pacific 15.9 11.8 2.9 4.0 0.8 9.9 16.6 0.1 −497.8 0.2 7908.9 0.2
Europe and Central Asia 31.0 32.7 5.4 4.7 − 12.7 11.8 − 1461.6 1.1 9847.3 0.4
Eastern Europe and Central
27.2 29.4 3.1 4.3 2.0 8.8 12.5 0.1 1461.6 1.1 − −
Asia
Western Europe 34.2 35.4 7.4 5.1 − 16.0 11.2 − − − 9847.3 0.4
Latin America and Caribbean 22.7 26.6 3.8 5.5 1.7 11.8 17.0 0.1 386.9 0.4 − −
Middle East and North Africa 27.4 27.9 2.8 − 0.9 9.4 − 0.0 1346.5 0.9 − −
North America 19.5 21.9 13.2 5.0 − 34.8 13.5 − − − 31625.9 0.2
South Asia 12.3 ‡ 15.3 0.8 3.5 1.3 3.3 13.7 0.1 3007.2 0.7 − −
Sub-Saharan Africa 14.5 16.9 1.5 4.3 1.0 7.0 17.7 29.9 2018.1 5.2 − −
Eastern and Southern Africa 17.6 17.9 2.0 4.6 1.4 8.9 19.0 43.8 1993.3 5.6 − −
West and Central Africa 11.3 15.1 0.9 3.8 0.7 5.1 15.9 − 2043.5 4.8 − −
Least developed countries 14.2 14.0 1.1 3.2 1.0 5.8 15.3 27.4 2196.7 6.6 − −
World 17.9 18.8 2.9 4.1 1.2 9.1 15.2 4.6 1447.8 1.3 11263.6 −
For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES

Government revenue as % of GDP – Revenue is cash
receipts from taxes, social contributions, and other revenues
such as fines, fees, rent, and income from property or sales.
Grants are also considered as revenue but are excluded here.
Government expenditure – General government final
consumption expenditure (formerly general government
consumption) includes all government current expenditures for
purchases of goods and services (including compensation of
employees). It also includes most expenditures on national
defence and security, but excludes government military
expenditures that are part of government capital formation.
Government expenditure expressed as a % of GDP –
Total government expenditure as well as the specific
expenditures on health, education, and social protection.
Government expenditure expressed as a % of Total
government expenditure – Specific expenditures on health,
education, and social protection.
ODA (Net official development assistance) – Official ODA – Organisation for Economic
development assistance flows are defined as those flows to Co-operation and Development. Last
countries and territories on the DAC List of ODA Recipients and update: February 2019.
to multilateral development institutions which are: (a) provided Government revenue as % of GDP
by official agencies, including state and local governments, or – World Development Indicators. Last
by their executive agencies; (b) each transaction of which is update: June 2019.
administered with the promotion of the economic development
and welfare of developing countries as its main objective; and Government Expenditure – World
Development Indicators. Last update:
(c) is concessional in character.
June 2019.
ODA (Net official development assistance) for donor
countries – expressed as an outflow of resources (in US
dollars and as % of Gross National Income).
ODA (Net official development assistance) for recipient NOTES
countries – expressed as an intflow of resources (in US
dollars and as % of Gross National Income). – Data not available.
* Data refer to the most recent year
available during the period specified
in the column heading.
** Excludes China.
‡ Excludes India.
 252 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 16. WOMEN’S ECONOMIC EMPOWERMENT

Legal Educational
frame- Demand attainment
Social works for family 2010–2017* Labour force participation rate 2010–2018* Unemployment rate 2010–2018* Mobile phone Financial
Institu- on planning ownership inclusion
tions gender Mater- Pater- satisfied upper secondary male female male female 2014–2017* 2014–2017*
and equality nity nity with
Gender in leave leave modern
Countries Index
(SIGI)
employ- bene- bene- methods
ment fits fits (%)
and areas 2019 2018 2018 2018 2013–2018* male female rural urban total rural urban total rural urban total rural urban total male female male female

Afghanistan Very high − No Yes 42 − − 73.9 71.2 73.2 22.9 16.2 21.2 9.7 12.4 10.4 8.6 35.6 14.0 − − 22.5 7.2
Albania Low 0.7 Yes Yes 5 46.2 44.5 − − − − − − − − − − − − − − 42.0 38.1
Algeria − − Yes Yes 77 28.1 x 22.7 x 65.5 57.3 60.0 10.2 15.0 13.5 − − − − − − − − 56.3 29.3
Andorra − − − − – 47.7 47.0 − − − − − − − − − − − − − − − −
Angola − − No No 24 19.9 12.3 89.0 72.9 79.9 90.2 63.2 74.9 1.6 12.1 7.0 0.7 15.4 7.7 77.6 79.8 36.1 22.3
Anguilla − − − − – − − − − − − − − − − − − − − − − − −
Antigua and Barbuda − − No No – − − − − − − − − − − − − − − − − − −
Argentina − − No Yes – 40.3 x 43.9 x − − − − − − − − − − − − − − 46.5 50.8
Armenia Low 0.8 Yes No 37 91.6 92.0 74.4 68.0 70.6 60.7 48.1 52.8 7.9 25.2 17.9 6.6 25.4 17.5 − − 55.8 40.9
Australia Very low 1.0 Yes Yes – 78.3 74.6 67.1 72.5 70.7 57.2 61.2 59.9 − − − − − − − − 99.9 99.2
Austria Very low − Yes No – 85.9 72.9 67.4 66.9 67.1 56.6 55.5 55.9 2.2 6.8 5.0 2.8 5.8 4.7 − − 97.9 98.4
Azerbaijan Low − Yes No 21 x 92.3 85.4 − − − − − − − − − − − − 88.4 79.7 29.4 27.7
Bahamas − − − − – 81.2 x 82.5 x − − − − − − − − − − − − − − − −
Bahrain − − No Yes – 39.3 46.8 − − − − − − − − − − − − 100.0 100.0 86.3 75.4
Bangladesh Very high 0.2 Yes No 73 34.0 23.9 80.4 81.2 80.7 38.6 31.0 36.3 3.2 3.5 3.3 5.9 9.0 6.7 54.3 30.9 64.6 35.8
Barbados − 0.4 No No 70 x 22.9 x 25.4 x − − − − − − − − − − − − − − − −
Belarus Low 0.5 Yes No 74 x 87.8 x 82.5 x − − − − − − − − − − − − 91.5 95.0 80.9 81.3
Belgium Very low − Yes Yes – 68.9 65.4 61.0 58.7 59.0 52.1 49.1 49.5 4.1 6.7 6.3 4.4 5.8 5.6 − − 98.5 98.8
Belize − − Yes No 66 36.4 37.3 81.3 77.4 79.5 41.5 56.6 48.8 4.4 4.8 4.6 11.5 8.5 9.8 − − 44.1 52.3
Benin Medium − Yes Yes 26 − − 78.0 70.1 74.4 73.3 65.3 69.7 1.1 4.1 2.4 1.7 4.4 2.9 − − 48.6 28.6
Bhutan − − No Yes 85 x 8.2 2.9 69.7 74.6 71.2 60.4 45.5 55.9 − − − − − − − − 39.0 27.7
Bolivia (Plurinational
Low − No Yes 50 46.5 39.0 90.8 75.8 80.3 77.3 58.4 63.8 0.9 4.8 3.5 0.8 5.1 3.6 − − 55.0 53.9
State of)
Bosnia and
Low − Yes Yes 22 x 74.9 50.9 53.0 52.8 52.9 27.3 36.7 31.4 15.9 19.1 17.2 21.2 19.5 20.3 − − 63.2 54.7
Herzegovina
Botswana − − No No – − − 71.1 x 68.6 x 69.6 x 53.1 x 57.5 x 55.8 x 11.9 x 13.8 x 13.0 x 19.0 x 19.9 x 19.6 x − − 56.2 46.8
Brazil Low 0.8 Yes Yes 89 x 41.6 45.7 82.1 77.1 77.9 55.0 56.3 56.1 2.3 x 7.0 x 6.2 x 5.2 x 12.1 x 11.1 x 82.6 83.6 72.9 67.5
British Virgin Islands − − − − – − − − − − − − − − − − − − − − − − −
Brunei Darussalam − − No No – − − 67.8 69.3 68.9 52.9 57.7 56.5 9.5 8.6 8.8 11.8 9.4 10.0 99.0 99.0 − −
Bulgaria Low 1.0 Yes Yes – 77.0 74.3 54.6 65.2 61.9 38.1 53.8 49.2 9.5 4.3 5.7 8.8 3.4 4.7 − − 70.6 73.6
Burkina Faso Medium − Yes Yes 55 4.3 1.6 76.6 69.1 74.6 59.3 55.1 58.3 3.3 5.9 3.9 9.5 8.5 9.3 − − 51.3 34.5
Burundi − − No Yes 37 4.5 2.3 79.1 69.4 77.9 82.7 54.8 79.8 1.1 9.6 2.1 0.5 10.5 1.2 16.0 7.3 7.5 6.7
Cabo Verde − 0.7 No Yes 73 x 20.3 19.8 65.8 55.5 62.5 54.6 36.1 48.7 30.5 − 31.0 30.3 − 31.6 74.7 73.8 − −
Cambodia Low − No No 56 47.3 29.4 89.1 84.9 88.1 77.8 70.3 75.9 0.6 0.5 0.6 0.9 0.6 0.9 − − 21.9 21.5
Cameroon Very high 0.4 Yes Yes 38 25.4 11.5 80.1 74.4 77.5 73.9 58.4 67.2 1.1 5.6 3.1 0.9 9.2 4.0 − − 39.2 30.0
Canada Very low − Yes No – 82.8 82.7 67.2 70.1 69.6 59.5 61.7 61.3 6.4 6.1 6.1 5.3 5.5 5.5 − − 99.6 99.9
Central African
High − Yes No 29 x − − − − − − − − − − − − − − − − 18.1 9.7
Republic
Chad High − Yes Yes 18 9.9 x 1.7 x − − − − − − − − − − − − − − 29.0 14.9
Chile Medium 0.8 Yes Yes – 58.2 56.0 72.5 70.5 70.8 41.9 50.3 49.2 4.5 7.1 6.7 7.3 8.1 8.0 86.7 97.2 77.8 71.3
China − − Yes Yes 97 x 25.4 19.2 − − − − − − − − − − − − − − 84.0 76.4
Colombia Very low 0.8 Yes Yes 86 46.3 48.2 86.2 78.8 80.5 46.3 59.6 57.0 2.6 8.6 7.1 8.4 12.4 11.8 71.8 74.5 49.5 42.5
Comoros − − Yes No 27 x − − 51.8 x 48.0 x 50.7 x 34.0 x 29.0 x 32.5 x 3.7 x 6.1 x 4.4 x 4.2 x 6.9 x 4.9 x − − 25.7 17.9
Congo − − Yes No 39 − − 77.4 x 64.1 x 69.1 x 79.6 x 58.5 x 66.9 x 6.2 x 27.4 x 18.5 x 6.7 x 33.9 x 21.0 x − − 31.2 21.0
Cook Islands − − − − – − − − − − − − − − − − − − − − − − −
Costa Rica Low 0.6 Yes No 89 x 37.3 39.2 75.4 73.4 74.0 39.3 48.7 46.4 7.4 8.3 8.0 14.5 11.6 12.2 87.3 87.1 75.5 60.9
Côte d'Ivoire High 0.8 Yes Yes 39 15.3 6.9 76.5 65.6 65.6 51.8 46.2 46.2 0.7 2.9 2.9 1.1 3.9 3.9 81.4 47.2 46.6 35.6
Croatia Very low 1.0 Yes No – 79.1 63.2 56.1 58.2 57.4 40.7 48.2 45.5 8.1 7.4 7.6 11.9 8.1 9.3 − − 89.8 82.7
Cuba − − − − 88 57.7 57.1 − − − − − − − − − − − − − − − −
Cyprus Low − Yes No – 72.8 69.7 62.6 69.1 67.8 51.5 58.8 57.4 8.6 7.9 8.0 9.4 8.6 8.7 100.2 98.7 87.3 90.0
Czechia Very low − Yes No – 94.4 86.4 67.8 69.3 68.7 52.1 53.2 52.8 1.6 1.9 1.8 2.8 2.8 2.8 97.2 96.9 83.6 78.6
Democratic People's
Low − − − 90 − − − − − − − − − − − − − − − − − −
Republic of Korea
Democratic Republic
Medium − Yes Yes 16 38.6 16.8 76.0 60.8 69.8 75.3 44.4 62.5 1.9 11.5 5.3 1.0 10.0 3.6 − − 27.4 24.2
of the Congo
Denmark Very low 0.9 Yes Yes – 77.5 78.8 63.6 68.6 66.6 55.3 60.4 58.4 3.9 5.3 4.8 4.2 5.7 5.1 82.5 83.2 99.8 100.0
Djibouti − − Yes Yes – − − − − − − − − − − − − − − 61.3 51.6 16.6 8.8
Dominica − − No No – 11.2 x 10.4 x − − − − − − − − − − − − − − − −
Dominican Republic Very low 0.9 Yes Yes 84 31.3 38.2 79.2 75.6 76.4 39.7 51.3 49.2 2.6 4.8 4.3 5.1 8.6 8.1 69.6 69.1 58.4 54.1
Ecuador Low − No Yes 80 x 42.6 42.0 85.3 76.6 79.3 61.1 51.9 54.6 1.0 3.9 2.9 1.5 5.8 4.4 59.1 58.0 60.2 42.6
Egypt − − No No 80 − − 68.5 64.8 66.9 22.2 21.7 22.0 7.0 9.9 8.2 18.8 28.6 23.0 98.6 97.1 38.7 27.0
El Salvador Low 0.9 Yes Yes 82 31.4 28.2 81.8 74.6 77.5 35.2 51.9 45.7 3.8 5.3 4.7 3.3 4.3 4.0 81.0 78.5 37.6 24.4
Equatorial Guinea − − No Yes 21 x − − − − − − − − − − − − − − − − − −
Eritrea − − No No 20 x − − − − − − − − − − − − − − − − − −
Estonia Very low − Yes Yes – 83.6 89.9 66.6 74.1 71.3 55.1 58.7 57.4 5.1 5.6 5.4 5.5 5.2 5.3 − − 97.6 98.4
 S TAT I S T I C A L TA B L E S » 2 5 3

TABLE 16. WOMEN’S ECONOMIC EMPOWERMENT

Legal Educational
frame- Demand attainment
Social works for family 2010–2017* Labour force participation rate 2010–2018* Unemployment rate 2010–2018* Mobile phone Financial
Institu- on planning ownership inclusion
tions gender Mater- Pater- satisfied upper secondary male female male female 2014–2017* 2014–2017*
and equality nity nity with
Gender in leave leave modern
Countries Index
(SIGI)
employ- bene- bene- methods
ment fits fits (%)
and areas 2019 2018 2018 2018 2013–2018* male female rural urban total rural urban total rural urban total rural urban total male female male female

Eswatini − − No No 81 − − 51.0 71.2 55.8 41.9 63.0 47.1 23.7 14.9 21.0 25.7 21.9 24.4 − − 29.7 27.4
Ethiopia Low − No No 62 12.7 5.7 87.8 73.3 85.0 78.6 60.5 74.6 − − − − − − − − 40.9 29.1
Fiji − 0.6 No No – 39.1 x 39.6 x 82.1 72.4 77.0 37.6 39.4 38.6 2.3 5.1 3.7 4.6 6.2 5.5 − − − −
Finland Very low 1.0 Yes Yes – 73.3 74.7 59.2 64.9 63.2 52.7 57.2 55.9 6.4 7.8 7.4 6.5 7.6 7.3 95.2 102.6 100.0 99.6
France Very low 0.9 Yes Yes 96 x 72.7 66.9 59.3 60.9 60.3 52.1 51.4 51.6 6.7 10.3 9.0 7.9 9.7 9.1 − − 97.0 91.3
Gabon High − Yes No 34 x − − − − − − − − − − − − − − − − 63.8 53.7
Gambia − − Yes Yes 24 − − 66.6 70.4 68.6 52.1 48.7 50.4 4.0 9.0 6.7 11.0 14.5 12.6 − − − −
Georgia Low − Yes No – 94.0 93.0 82.1 68.4 74.6 70.6 49.4 58.2 5.6 24.3 15.0 4.5 21.1 12.7 88.9 81.5 58.5 63.6
Germany Very low 1.0 Yes No – 87.6 78.6 67.7 66.5 66.8 57.1 55.6 55.9 2.5 4.2 3.8 2.2 3.1 2.9 − − 99.1 99.2
Ghana Medium − No No 46 27.2 14.7 53.1 64.1 58.8 50.3 59.5 55.3 2.0 5.6 4.1 2.4 5.8 4.4 − − 61.8 53.7
Greece Low 1.0 Yes Yes – 57.0 52.4 58.5 60.7 60.0 40.9 45.6 44.3 13.5 16.1 15.4 20.3 25.6 24.2 − − 86.5 84.5
Grenada − − No No – − − − − − − − − − − − − − − − − − −
Guatemala Low 0.6 No Yes 65 25.9 27.4 89.4 81.3 85.2 30.2 47.0 39.2 1.1 2.8 1.9 2.9 3.8 3.5 − − 46.4 42.1
Guinea Very high − Yes No 21 − − 73.3 x 54.5 x 66.4 x 70.1 x 45.2 x 62.8 x 1.9 x 14.6 x 5.7 x 1.7 x 10.5 x 3.6 x − − 27.3 19.7
Guinea-Bissau − − No No 38 − − − − − − − − − − − − − − − − − −
Guyana − − No No 52 29.0 x 33.2 x 68.1 70.8 68.9 40.1 52.4 43.6 9.9 9.8 9.9 15.5 15.0 15.3 − − − −
Haiti Medium − No No 41 − − 80.1 67.2 74.0 59.0 49.3 53.9 4.8 19.0 10.9 9.8 22.3 15.9 − − 35.4 30.1
Holy See − − − − – − − − − − − − − − − − − − − − − − −
Honduras Low − No No 76 x 23.4 25.8 91.7 77.3 84.0 37.2 51.6 45.6 0.8 5.5 3.1 3.3 6.6 5.5 − − 50.2 41.0
Hungary Low − Yes Yes – 80.8 71.9 66.6 65.4 65.8 48.7 48.7 48.7 4.4 3.1 3.5 4.4 3.8 4.0 − − 78.2 72.2
Iceland − − Yes Yes – 66.6 x 54.8 x 87.3 85.2 85.5 78.6 77.8 77.9 2.3 2.9 2.8 1.3 2.6 2.5 − − − −
India Medium 0.3 Yes No 66 34.2 19.4 80.5 76.0 79.1 25.7 17.8 23.3 2.1 3.2 2.4 2.8 6.6 3.7 − − 83.0 76.6
Indonesia High − No Yes 78 37.8 29.8 85.1 79.2 81.8 54.7 50.1 52.2 3.0 5.5 4.4 2.9 4.9 3.9 65.3 53.8 46.3 51.4
Iran (Islamic Republic
Very high − Yes Yes 69 x 47.9 48.9 66.3 63.3 64.1 16.1 14.5 14.9 − − − − − − 77.2 54.6 96.5 91.6
of)
Iraq Very high 0.6 Yes No 55 34.4 23.9 73.6 72.0 72.4 6.9 12.7 11.2 5.9 7.7 7.2 3.7 16.3 12.4 83.1 56.7 25.8 19.5
Ireland Very low − Yes Yes – 68.1 73.3 67.1 69.6 68.5 52.9 58.2 56.0 5.1 6.3 5.8 5.5 5.8 5.7 83.0 83.0 95.4 95.3
Israel − − Yes No – 81.6 81.3 70.3 68.1 68.2 64.2 59.4 59.8 − − − − − − − − 91.9 93.7
Italy Very low − Yes Yes – 50.2 48.2 58.8 59.5 59.4 39.6 41.5 41.1 8.9 10.0 9.7 11.4 11.9 11.8 92.7 90.4 96.1 91.6
Jamaica Low − No No 79 x − − 75.6 70.9 73.2 59.3 61.9 60.7 − − − − − − 95.6 97.2 79.2 77.8
Japan Low − Yes No – 81.7 79.1 − − − − − − − − − − − − 89.7 87.0 98.5 98.1
Jordan Very high 0.2 No No 57 42.5 40.1 − − − − − − − − − − − − − − 56.3 26.6
Kazakhstan Low − Yes No 82 86.0 x 84.6 x − − − − − − − − − − − − 87.1 86.5 56.9 60.3
Kenya Medium 0.9 No Yes 78 25.7 18.0 75.7 80.1 77.5 73.8 67.6 71.5 1.1 4.6 2.6 0.8 6.7 2.9 46.0 43.7 85.8 77.8
Kiribati − − No No 36 x − − − − − − − − − − − − − − − − − −
Kuwait − − No No – 26.4 36.3 − − − − − − − − − − − − − − 83.3 73.5
Kyrgyzstan Low − Yes No 65 89.7 x 87.1 x 75.4 74.8 75.0 50.2 43.3 45.9 1.9 8.6 3.9 3.0 7.7 4.2 − − 41.2 38.9
Lao People's
Low − Yes Yes 61 x − − 39.0 58.6 45.2 30.4 49.3 36.5 13.7 6.5 10.7 10.8 4.0 7.8 − − 26.1 31.9
Democratic Republic
Latvia Very low − Yes Yes – 87.5 91.1 65.1 70.4 68.4 51.6 58.0 55.8 9.4 7.9 8.4 7.5 5.9 6.4 − − 94.1 92.5
Lebanon Very high 0.5 No No – 33.4 x 32.5 x − − − − − − − − − − − − − − 56.7 32.9
Lesotho Medium − No No 76 13.4 x 14.2 x − − − − − − − − − − − − − − 44.6 46.5
Liberia High − Yes No 37 − − 91.1 74.7 82.3 83.6 62.8 72.2 1.0 6.7 3.8 0.6 4.3 2.4 − − 43.7 28.2
Libya − − Yes No 24 − − − − − − − − − − − − − − − − 70.7 59.6
Liechtenstein − − − − – 80.9 x 62.5 x − − − − − − − − − − − − − − − −
Lithuania Very low 1.0 Yes Yes – 88.5 84.0 64.2 69.8 67.6 50.0 60.0 56.5 10.0 5.1 6.9 8.0 4.2 5.4 96.9 97.2 85.1 81.0
Luxembourg − − Yes Yes – 83.4 75.7 60.9 65.8 63.9 54.5 56.7 55.8 3.6 6.3 5.3 4.7 6.6 5.9 − − 99.4 98.2
Madagascar High 0.4 Yes No 60 − − 91.6 79.9 89.2 86.9 72.0 83.6 0.9 5.5 1.8 0.6 6.8 1.8 − − 19.6 16.3
Malawi High − No No 75 − − 55.8 75.1 59.9 46.6 65.3 50.4 23.8 13.2 21.0 37.1 35.5 36.7 52.1 32.8 37.9 29.9
Malaysia − 0.3 No No – 58.1 58.6 82.7 79.4 80.2 49.2 55.8 54.3 − − − − − − 96.6 94.5 87.9 82.5
Maldives − − No Yes 43 x 6.4 x 4.1 x 77.3 80.3 78.5 46.1 47.7 46.8 − − − − − − − − − −
Mali High − Yes Yes 33 8.2 3.2 83.9 75.3 81.4 58.9 45.9 55.1 0.5 4.0 1.4 0.3 4.5 1.3 − − 45.5 25.7
Malta Low − Yes Yes – 39.1 37.0 70.1 69.7 69.7 53.7 48.8 49.0 4.5 3.8 3.8 6.9 3.6 3.6 − − 97.8 97.0
Marshall Islands − − No No 80 x 72.0 67.6 − − − − − − − − − − − − − − − −
Mauritania − − Yes No 30 − − 62.6 63.0 62.8 29.4 26.3 28.0 3.5 13.6 8.5 5.2 22.8 12.4 − − 26.3 15.5
Mauritius − − Yes Yes 41 47.6 39.8 − − − − − − − − − − − − 78.2 71.0 92.7 87.1
Mexico Low 0.8 No Yes 81 34.4 32.3 81.2 76.3 77.4 31.0 46.9 43.5 1.9 3.6 3.2 2.4 3.6 3.4 73.2 69.9 41.1 33.3
Micronesia
− − No No – − − − − − − − − − − − − − − − − − −
(Federated States of)
Monaco − − − − – − − − − − − − − − − − − − − − − − −
Mongolia Low − Yes No 67 63.8 71.1 76.3 60.0 65.6 66.9 47.9 54.0 3.9 9.0 7.0 4.0 6.8 5.7 − − 90.8 95.0
Montenegro − − Yes No 34 80.4 65.2 − − − − − − − − − − − − − − 69.2 67.6
Montserrat − − − − – − − − − − − − − − − − − − − − − − −
 254 | U N I C E F – T H E S TAT E O F T H E WO R L D ’ S C H I L D R E N 2 0 1 9

TABLE 16. WOMEN’S ECONOMIC EMPOWERMENT

Legal Educational
frame- Demand attainment
Social works for family 2010–2017* Labour force participation rate 2010–2018* Unemployment rate 2010–2018* Mobile phone Financial
Institu- on planning ownership inclusion
tions gender Mater- Pater- satisfied upper secondary male female male female 2014–2017* 2014–2017*
and equality nity nity with
Gender in leave leave modern
Countries Index
(SIGI)
employ- bene- bene- methods
ment fits fits (%)
and areas 2019 2018 2018 2018 2013–2018* male female rural urban total rural urban total rural urban total rural urban total male female male female

Morocco Very high − Yes Yes 69 − − 79.7 69.6 73.6 35.6 17.6 24.7 − − − − − − 91.6 91.7 41.5 16.8
Mozambique Low 0.7 No Yes 50 10.7 7.8 84.3 72.6 80.1 86.9 61.7 78.1 1.1 7.4 3.2 0.6 11.8 3.7 − − 51.1 32.9
Myanmar High − Yes Yes 75 − − 79.5 72.1 77.3 48.7 45.5 47.7 1.0 1.7 1.2 1.7 2.7 2.0 − − 26.0 26.0
Namibia Low − No No 75 19.0 x 16.3 x 53.6 70.2 62.7 48.8 61.1 55.4 16.0 24.4 21.1 13.1 22.4 18.6 − − 80.6 80.7
Nauru − − − − 42 x − − − − − − − − − − − − − − − − − −
Nepal Medium − No No 56 24.8 10.2 47.9 60.1 53.8 21.2 32.3 26.3 11.9 9.0 10.3 13.3 12.9 13.1 − − 50.0 41.6
Netherlands Very low 1.0 Yes Yes – 73.9 66.2 69.3 69.6 69.6 58.1 59.2 59.1 2.4 3.9 3.7 3.1 4.1 4.0 86.1 82.4 99.4 99.8
New Zealand Very low − Yes No – 71.9 68.3 80.7 75.6 76.2 70.3 64.8 65.4 − − − − − − − − 99.0 99.3
Nicaragua Very low − No Yes 93 x − − 90.3 78.1 83.3 34.5 56.2 48.0 1.4 6.0 3.8 4.9 5.9 5.6 − − 37.4 24.8
Niger − − Yes Yes 45 5.0 2.0 90.0 70.3 86.0 68.0 40.1 63.0 0.3 2.3 0.6 − 3.1 0.4 76.6 55.4 19.9 10.9
Nigeria High 0.3 No No 38 50.6 x 39.0 x 58.0 54.0 56.4 48.1 49.2 48.6 4.8 7.7 6.0 3.8 10.5 6.5 49.0 32.4 51.4 27.3
Niue − − − − – − − − − − − − − − − − − − − − − − −
North Macedonia − − Yes Yes 22 x − − 71.7 65.8 67.5 44.8 42.4 43.0 17.1 23.1 21.3 18.2 20.5 19.9 − − 80.4 72.9
Norway Very low − Yes No – 78.3 77.4 64.6 67.6 66.4 59.0 63.7 61.8 3.3 4.5 4.0 3.1 3.8 3.5 − − 99.5 100.0
Oman − − No No 40 45.3 63.2 81.3 89.3 87.8 20.6 32.8 29.8 − − − − − − 94.2 86.5 83.8 63.5
Pakistan Very high 0.0 No No 49 34.2 20.7 82.3 77.5 80.3 28.1 11.7 21.9 3.6 4.5 4.0 3.1 10.2 4.6 − − 34.6 7.0
Palau − − No No – 88.3 87.7 − − − − − − − − − − − − − − − −
Panama − 0.7 Yes Yes 74 40.1 45.8 80.1 74.3 76.0 44.5 51.8 49.7 1.8 3.7 3.1 3.7 5.5 5.1 − − 50.9 42.3
Papua New Guinea − − No No 41 x − − 47.5 57.1 49.0 46.9 52.5 47.7 2.5 13.4 3.7 0.9 7.9 1.4 − − − −
Paraguay Medium 1.0 Yes Yes 83 36.3 36.9 87.2 82.7 84.4 55.1 61.8 59.5 3.7 6.3 5.3 6.6 8.0 7.5 − − 51.2 46.1
Peru Low 1.0 Yes Yes 67 60.6 51.5 91.9 80.5 82.9 85.5 64.4 68.6 0.5 4.3 3.4 0.4 4.6 3.5 69.4 65.1 51.0 34.4
Philippines Very high 0.9 No Yes 53 56.8 60.1 73.7 71.0 72.5 43.4 47.8 45.4 1.6 2.8 2.1 2.3 3.1 2.7 − − 30.0 38.9
Poland Very low − Yes Yes – 87.4 82.5 64.8 65.1 64.9 46.5 49.8 48.5 4.2 3.6 3.8 4.5 3.5 3.8 − − 85.4 88.0
Portugal Very low − Yes Yes – 35.3 38.1 63.2 64.8 64.4 49.9 56.0 54.5 5.7 6.8 6.6 6.6 7.7 7.4 − − 94.2 90.6
Qatar − − No No 69 x 36.9 58.7 − 96.1 96.1 − 58.5 58.5 − − − − − − 99.7 99.6 68.6 61.6
Republic of Korea − − − Yes – 82.7 70.4 76.1 73.3 73.8 55.5 52.8 53.3 2.6 4.2 3.9 2.5 3.9 3.7 95.6 93.1 95.0 94.7
Republic of Moldova Low − Yes Yes 60 x 76.1 73.5 44.9 47.0 45.8 42.4 39.4 41.0 2.4 4.9 3.5 1.2 4.1 2.5 − − 42.9 44.6
Romania Very low − Yes Yes – 72.0 61.3 65.0 64.9 64.9 42.7 47.4 45.6 5.2 4.4 4.7 4.0 3.2 3.5 − − 62.4 53.6
Russian Federation Low − Yes No – 85.9 83.5 67.3 72.7 71.3 49.9 57.7 55.9 7.3 4.1 4.9 7.4 4.1 4.8 − − 75.3 76.1
Rwanda Low − No Yes 65 10.8 6.5 57.6 70.2 60.7 40.8 56.8 44.3 15.4 16.5 15.7 18.9 20.4 19.4 − − 55.8 45.0
Saint Kitts and Nevis − − No No – − − − − − − − − − − − − − − − − − −
Saint Lucia − − No No 72 x 37.8 42.8 − − − − − − − − − − − − − − − −
Saint Vincent and the
− − No No – − − − − − − − − − − − − − − − − − −
Grenadines
Samoa − − No Yes 39 70.4 74.6 53.7 60.0 55.0 28.9 41.9 31.5 10.8 9.8 10.6 24.0 13.9 21.3 − − − −
San Marino − − Yes No – − − − − − − − − − − − − − − − − − −
Sao Tome and
− − Yes No 51 − − − − − − − − − − − − − − − − − −
Principe
Saudi Arabia − − No Yes – 50.9 45.7 − − − − − − − − − − − − 95.9 92.0 80.5 58.2
Senegal Medium − Yes Yes 50 17.3 5.0 61.8 54.6 58.0 33.4 35.5 34.5 3.3 9.5 6.4 3.4 10.8 7.3 − − 46.7 38.5
Serbia Very low 1.0 Yes Yes 25 77.5 65.8 65.5 60.9 62.9 45.9 47.2 46.7 10.0 13.5 12.0 12.3 14.6 13.7 92.5 91.1 72.9 70.1
Seychelles − − Yes Yes – 48.0 x 44.2 x − − − − − − − − − − − − − − − −
Sierra Leone High − No No 45 − − 49.3 62.4 57.6 46.3 61.7 56.3 11.9 2.7 5.6 6.9 2.7 3.9 − − 24.8 15.4
Singapore Low − Yes Yes – 73.8 67.8 − − − − − − − − − − − − 91.0 88.1 99.7 96.3
Slovakia Very low − Yes No – 91.6 83.0 67.3 68.2 67.8 50.1 53.9 52.3 8.1 4.6 6.1 8.7 5.9 7.0 − − 85.3 83.1
Slovenia Very low 0.9 Yes Yes – 86.6 77.3 64.4 63.6 64.0 54.0 53.6 53.8 3.8 5.3 4.6 5.5 5.9 5.7 − − 98.2 96.9
Solomon Islands − − No No 38 − − − − − − − − − − − − − − − − − −
Somalia − − − − – − − − − − − − − − − − − − − − − 43.6 33.7
South Africa Low − Yes Yes 73 66.6 62.8 48.1 69.0 62.4 35.3 55.0 48.4 28.8 24.0 25.1 31.8 28.2 29.1 117.1 56.5 68.4 70.0
South Sudan − − No No 6 x 16.2 x 10.9 x − − − − − − − − − − − − − − 12.5 4.7
Spain Very low 1.0 Yes Yes – 48.9 48.4 58.8 64.5 63.7 45.8 53.4 52.4 13.1 13.8 13.7 17.8 16.9 17.0 − − 95.9 91.6
Sri Lanka High − No No 74 60.1 63.0 75.5 72.6 75.0 36.9 30.2 35.8 2.8 3.0 2.8 6.8 6.0 6.7 − − 73.9 73.4
State of Palestine − 0.4 No No 65 39.7 39.6 − − − − − − − − − − − − 81.8 65.3 34.4 15.9
Sudan − − No No 30 − − 72.6 65.9 70.1 30.3 25.3 28.3 11.5 13.9 12.4 24.5 42.3 30.7 70.3 54.2 20.2 10.0
Suriname − − No No 73 x 23.1 26.2 − − − − − − − − − − − − − − − −
Sweden Very low 1.0 Yes Yes – 76.1 75.0 73.4 76.3 75.5 68.7 71.6 70.8 6.0 6.5 6.4 5.5 6.6 6.3 − − 99.5 100.0
Switzerland Very low − Yes No – 88.5 80.7 74.8 74.1 74.2 66.5 62.1 62.9 3.1 4.7 4.4 3.4 5.5 5.1 − − 98.0 98.9
Syrian Arab Republic − − Yes No 53 x 24.8 x 18.9 x − − − − − − − − − − − − − − 26.8 19.6
Tajikistan Medium − Yes No 45 85.2 76.1 56.5 x 54.4 x 56.0 x 29.4 x 28.3 x 29.1 x 6.3 x 8.3 x 6.8 x 2.9 x 6.7 x 3.9 x − − 52.1 42.1
Thailand Medium − No No 89 33.5 31.9 77.3 75.6 76.5 58.9 60.6 59.7 0.7 0.8 0.8 0.7 0.8 0.7 81.7 81.2 83.7 79.8
Timor-Leste − − No Yes 38 − − 74.8 65.0 72.6 64.8 49.6 61.4 1.9 8.9 3.3 3.7 17.8 6.3 − − − −
Togo High − Yes Yes 32 17.4 3.0 53.2 45.0 49.4 68.6 52.8 61.2 0.7 5.4 2.7 2.5 4.2 1.7 48.6 39.5 53.1 37.6
Tokelau − − − − – − − − − − − − − − − − − − − − − − −
 S TAT I S T I C A L TA B L E S » 2 5 5

TABLE 16. WOMEN’S ECONOMIC EMPOWERMENT

Legal Educational
frame- Demand attainment
Social works for family 2010–2017* Labour force participation rate 2010–2018* Unemployment rate 2010–2018* Mobile phone Financial
Institu- on planning ownership inclusion
tions gender Mater- Pater- satisfied upper secondary male female male female 2014–2017* 2014–2017*
and equality nity nity with
Gender in leave leave modern
Countries Index
(SIGI)
employ- bene- bene- methods
ment fits fits (%)
and areas 2019 2018 2018 2018 2013–2018* male female rural urban total rural urban total rural urban total rural urban total male female male female

Tonga − − No No 48 x 53.1 55.1 − − − − − − − − − − − − − − − −

Trinidad and Tobago Low 0.8 Yes No 58 x 56.8 x 56.6 x − − − − − − − − − − − − − − 88.2 73.6
Tunisia High − No Yes 73 x 50.1 39.3 72.9 68.7 70.0 18.1 29.3 25.6 13.5 13.1 13.3 22.3 23.2 23.0 − − 45.7 28.4
Turkey Low − Yes Yes 60 40.1 28.5 − − − − − − − − − − − − − − 83.0 54.3
Turkmenistan − − − − 76 − − − − − − − − − − − − − − − − 45.7 35.5
Turks and Caicos
− − − − – − − − − − − − − − − − − − − − − − −
Islands
Tuvalu − − − − 41 x − − − − − − − − − − − − − − − − − −
Uganda High 0.8 No Yes 54 13.9 6.3 56.6 76.7 61.8 39.3 59.9 45.0 2.4 4.8 2.9 2.5 12.4 4.3 − − 66.1 52.7
Ukraine Low 0.5 Yes No 68 x 78.4 x 71.1 x 67.1 70.0 69.0 54.2 57.9 56.8 − − − − − − − − 65.0 61.3
United Arab Emirates − 0.1 No No – 43.0 x 59.9 x − − − − − − − − − − − − 99.4 99.4 92.7 76.4
United Kingdom Very Low 0.9 Yes Yes – 76.1 73.3 63.9 69.0 68.3 54.9 58.5 58.0 2.9 4.2 4.0 2.8 4.1 3.9 − − 96.7 96.1
United Republic of
High 0.8 No Yes 52 4.6 2.3 91.0 83.4 88.1 85.6 71.7 80.1 0.5 3.4 1.6 0.7 6.3 2.7 − − 51.6 42.2
Tanzania
United States Very low − No No – 88.5 89.6 64.1 70.1 69.1 53.2 57.9 57.1 4.4 3.9 3.9 4.0 3.8 3.8 − − 93.6 92.7
Uruguay Low − Yes Yes – 26.2 33.4 76.7 71.8 72.1 50.7 56.2 56.0 2.5 7.2 6.9 7.4 10.2 10.1 78.3 79.8 67.6 60.6
Uzbekistan − − Yes No – 94.2 91.0 − − − − − − − − − − − − − − 38.3 36.0
Vanuatu − − No No 51 − − 82.0 x 68.3 x 78.2 x 63.3 x 51.5 x 60.2 x 2.2 x 9.9 x 4.1 x 2.4 x 14.7 x 5.2 x − − − −
Venezuela (Bolivarian
− − − − – 58.6 65.2 76.3 69.0 69.4 31.7 45.6 45.0 − − − − − − − − 77.3 70.0
Republic of)
Viet Nam Low 0.7 Yes Yes 69 30.4 x 21.4 x 84.9 74.3 81.2 76.8 62.6 71.6 1.7 3.2 2.2 1.5 2.7 1.9 − − 31.2 30.4
Yemen Very high − − − 38 − − 65.1 66.5 65.4 5.4 8.2 6.0 12.9 10.4 12.3 24.9 29.1 26.1 − − 11.4 1.7
Zambia Medium − No No 64 − − 33.6 58.9 45.2 20.4 36.4 27.8 12.2 10.0 10.9 9.9 14.6 12.7 − − 51.7 40.3
Zimbabwe Medium − Yes No 85 19.1 12.0 89.8 69.6 82.0 94.5 86.6 91.9 1.2 12.1 4.7 1.1 19.1 6.0 − − 59.2 51.7

SUMMARY
East Asia and Pacific − − − − – 35.0 29.4 80.1 ** 75.4 ** 77.9 ** 56.1 ** 53.4 ** 54.9 ** 2.2 ** 3.9 ** 3.0 ** 2.2 ** 3.5 ** 2.8 ** 77.8 ** 71.1 ** 74.2 70.2
Europe and Central
− − − − – 73.0 67.8 64.4 66.7 66.2 50.5 53.6 52.9 6.1 6.5 6.4 6.8 6.8 6.7 − − 82.8 78.6
Asia
Eastern Europe
− − − − – 73.9 67.7 66.2 69.4 68.6 48.8 54.1 52.8 7.2 5.6 5.8 7.3 5.4 5.5 − − 68.2 61.4
and Central Asia
Western Europe − − − − – 72.4 67.9 63.5 65.2 64.9 51.4 53.3 52.9 5.6 6.9 6.6 6.6 7.4 7.2 − − 95.3 93.4
Latin America and
− − − − – 42.0 43.1 82.8 76.4 78.0 47.8 53.5 52.3 2.3 6.2 5.2 4.7 9.1 8.3 77.2 77.1 58.1 51.6
Caribbean
Middle East and
− − − − 67 − − 69.4 65.7 67.2 18.5 18.3 18.5 − − − − − − 89.7 79.3 55.6 42.0
North Africa
North America − − − − – 88.0 88.9 64.4 70.1 69.1 53.8 58.3 57.5 4.6 4.1 4.2 4.1 4.0 4.0 − − 94.2 93.4
South Asia − − − − 64 34.3 20.4 80.0 76.2 78.8 27.2 18.6 24.5 2.6 3.6 2.9 3.5 7.7 4.5 − − 73.8 62.8
Sub-Saharan Africa − − − − 47 22.5 13.8 70.9 67.2 69.9 60.7 54.3 58.8 5.0 9.5 6.2 5.8 13.3 7.9 − − 45.9 34.1
Eastern and
− − − − 59 21.9 16.0 74.3 73.9 75.2 63.7 59.5 63.0 6.6 11.1 7.4 8.2 17.1 10.3 − − 48.7 40.0
Southern Africa
West and Central
− − − − 35 − 10.3 67.4 60.4 64.6 57.7 49.1 54.5 3.0 7.7 4.9 2.8 8.9 5.1 − − 43.0 27.9
Africa
Least developed
− − − − 52 21.8 12.1 76.3 71.9 74.9 55.1 46.1 52.1 3.5 7.4 4.5 5.2 12.2 6.9 − − 40.2 27.8
countries
World − − − − 63 41.1 33.9 75.7 72.7 74.5 46.1 43.4 45.6 3.3 5.2 4.1 4.0 7.0 5.0 − − 69.6 62.2

For a complete list of countries and areas in the regions, subregions and country categories, see page 182 or visit <data.unicef.org/regionalclassifications>.
It is not advisable to compare data from consecutive editions of The State of the World’s Children.

DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES NOTES

Social Institutions and Gender Index (SIGI) – Level of
gender discrimination in social institutions defined as
discrimination in the family, restricted physical integrity,
restricted access to reproductive and financial resources,
and restricted liberties.
Legal frameworks that promote, enforce and monitor
gender equality in employment and economic
benefits – Measures as a percentage of achivement from
0 to 100 with 100 being best practice, government efforts
to put in place legal frameworks that promote, enforce and
monitor gender equality in the area of employment and
economic benefits.
Maternity leave benefits – Whether the law provides
for 14 weeks or more of paid maternity leave in accordance
with the International Labour Organization standards.
Paternity leave benefits – Whether the law provides for
paid paternity leave (of any length).
Demand for family planning satisfied with modern
methods – Percentage of married or in union women of
reproductive age (15−49 years) who have their need for
family planning satisfied with modern methods.
Educational attainment – Percentage of the population
aged 25 years and older that completed at least upper
secondary education (ISCED 3).
Labour force participation rate – The labour force Social Institutions and Gender and Health Surveys (DHS), Multiple − Data not available.
participation rate is calculated as the labour force during a Index (SIGI) – Organisation for Indicator Cluster Surveys (MICS), x Data refer to years or periods other than
given reference period expressed as a percentage of the Economic Co-operation and Reproductive Health Surveys, other
those specified in the column heading.
working-age population in the same reference period. The Development (OECD). Last update: national surveys, National Health
Such data are not included in the calcu-
labour force (formerly known as currently active March 2019. Information Systems (HIS). Last updated:
population) comprises all persons of working age who February 2019. lation of regional and global averages.
Legal frameworks that promote, Estimates from data years prior to 2000
furnish the supply of labour for the production of goods and enforce and monitor gender Educational attainment – UNESCO
services (as defined by the United Nations System of are not displayed.
equality in employment and Institute for Statistics (UIS). Last update:
National Accounts (SNA) production boundary) during a economic benefits – SDG Global June 2019. * Data refer to the most recent year
specified time-reference period. It is measured in relation Database. Last update: July 2019. available during the period specified in
to a short reference period such as one week or one day. It Labour force participation rate –
Maternity leave benefits – World International Labour Organization (ILO). the column heading.
refers to the sum of all persons of working age who are
employed and those who are unemployed. Bank Women Business and the Law. Last update: August 2019. ** Excludes China.
Last update: February 2019. Unemployment rate – International
Unemployment rate – The percentage of persons in the
labour force who are unemployed. Paternity leave benefits – World Labour Organization (ILO). Last update:
Bank Women Business and the Law. August 2019.
Mobile phone ownership – Proportion of individuals Last update: February 2019.
who own a mobile telephone. Mobile phone ownership –SDG
Demand for family planning Global Database. Last update: July
Financial inclusion – The percentage of adults (ages satisfied with modern methods 2019.
15+) who report having an account (by themselves or – United Nations, Department of
together with someone else) at a bank or another type of Financial inclusion – SDG Global
Economic and Social Affairs, Population Database. Last update: July 2019.
financial institution or personally using a mobile money Division (2019), based on Demographic
service in the past 12 months.
For the first time in 20 years, UNICEF’s The State
of the World’s Children examines the issue of
children, food and nutrition, providing a fresh
perspective on a rapidly evolving challenge.
Despite progress in the past two decades, one
third of children under 5 are malnourished –
stunted, wasted or overweight – while two thirds
are at risk of malnutrition and hidden hunger
because of the poor quality of their diets. These
patterns reflect a profound triple burden of
malnutrition – undernutrition, hidden hunger and
overweight – that threatens the survival, growth
and development of children and of nations.
At the center of this challenge is a broken food
system that fails to provide children with the diets
they need to grow healthy. This report provides
new data and analyses of malnutrition in the 21st
century and outlines recommendations to put
children’s rights at the heart of food systems.

ISBN: 978-92-806-5003-7

9 789280 650037
© United Nations Children’s Fund (UNICEF)
October 2019

FOR EVERY CHILD, NUTRITION